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ee S ea Janel Heinrich,MPH,MA,Director <br /> ' 'se e° Public H e a l t h Health Division <br /> 2300 S Pa rk St,R m 2 010 608 242-6515 <br /> 608 242-6435 fax <br /> MADISON &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 Phone: <br /> and Owner(if not applicant) <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 Blk 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 ❑ Aerobic Treatment Unit ❑ Seepage Bed <br /> ❑ Seepage Trench ❑ Seepage Pit(Drywell) Dir 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.: /q a Describe Remodeling:. 6q.s,<_Mf"civ'r Fv.,/tt 4 <br /> ❑ Detached Accessory Structure(Specify:Garage,Pole Barn,Shed,etc.): Will there be plumbing?❑Yes❑No <br /> I Addition /ten L' <br /> if addition,what is the size of the addition: bV sq.ft.,Dimensions: /-7 )C D ,Type:5cia F- / Poiach <br /> `If addition,does the addition contain bedrooms:❑Yes E No If yes,how many: <br /> Total number of bedrooms after addition: <br /> n ,If addition total number of people using structure/system after addition: <br /> Other: Ftdi�Z G 7-h &ji/2-0 ) 'S<:/Yl F_�t/f <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 /> in•icates t/ is r r ssion is given to inspect the property for the purpose of this review. <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 />