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••:•• Janel Heinrich,MPH,MA,Director <br /> ••• •• Public• <br /> • Health Environmental Health Division 608 242-6515 <br /> 2300 S Park St,Rm 2010 608 242-6435 fax <br /> MADISON Sc DANE COUNTY Madison,WI 53713 www.publichealthmdc.com <br /> Healthy people and places Building Permit Review Application <br /> Applicant(Owner or Authorized Agent) John&Amy Hippen <br /> Phone: <br /> and Owner(If not apprcanq <br /> Address of Property Owner or 3724 Cardinal Point Trail,Verona,WI 53593 <br /> Authorized Agent: <br /> NW 1/4, SW 1/4, Section:20 Township:Middleton <br /> Location of Property: <br /> Subdivision:Spruce Bik Lot 47 <br /> Hollow, <br /> Parcel Number: 0708/203/2057/0 <br /> Property Address: 3724 Cardinal Point Trail <br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS): <br /> Type of POWTS:(check all that apply): <br /> ❑ Septic Tank El Aerobic Treatment Unit ❑ Seepage Bed <br /> ❑ Seepage Trench ❑ Seepage Pit(Drywell) (id" Mound <br /> ❑ At Grade ❑ Inground Pressure ❑ Cesspool <br /> Other(explain): <br /> Date of POWTS Installation(if known):9/23/05-mound;5/17/06-tanks Owner at time of Installation:Veridian Homes <br /> Size of POWTS:Tank:1650 gallons,Soil Absorption Area:756 Square Feet, Last Pumped:4/30/15 <br /> Age of Existing House:2006 years,Size of Existing House: Square Feet,Number of Bedrooms:5 <br /> TYPE OF PROPOSED CONSTRUCTION: <br /> ❑ New Structure ❑ Replacement Structure(Fire,Tornado,Flood,Mobile Home Replacement,etc.): <br /> • Remodeling If remodeling,how many Sq.Ft.: /y/t) Describe Remodeling:. 845"E/i t/c/rr FT-n/yy <br /> ❑ Detached Accessory Structure(Specify:Garage,Pole Barn,Shed,etc.): Will there be plumbing?El Yes❑No <br /> g Addition //���/� / /� / <br /> if addition,what is the size of the addition: .€b sq.ft.,Dimensions: / / )( 0 ,Type:5C-20 Eit/ Po.2cl. <br /> `If addition,does the addition contain bedrooms:El Yes ENo If yes,how many: <br /> Total number of bedrooms after addition: ,If addition total number of people using structure/system after addition: <br /> Other: f't1-9.s 6 T-1-7 r- <br /> (POWTS sizing is based on 2 people per bedroom using 75 gallons of water per person per day.) <br /> PLOT PLAN: <br /> Provide a drawing of your property drawn to scale or adequately dimensioned showing lot lines,well(s),existing POWTS and <br /> POWTS replacement area(if known),all existing structure(s),proposed construction(dotted lines,or clearly labeled)and distances <br /> between above. <br /> If a POWTS is found to be a cesspool or is found discharging onto the surface of the ground or into ground water,surface <br /> water,or bedrock on the above property,this will be considered POWTS failure and the failing POWTS will be ordered <br /> corrected. <br /> Signature of own- .r authorized agent is required and indicates the above information is accurate to the best of your knowledge <br /> i//n.icates t/- %-r's .-r r ssion is given to inspect the property for the purpose of this review. <br /> Iii`f .` 5 -;5- / 7 <br /> • ner/Authorized Agent Date <br /> Allow at least two(2)weeks for review to be completed,after required information is received. <br /> 5/9/2017-Building Permit Review Application 3-13.doc <br />