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••c,.. _o s ublic Health <br /> MADISON S DANE COUNTY Janel Heinrich, MPH,MA,Director <br /> Health le and laces Environmental Health Division _ 608 242-6515 Well&Septic <br /> yp eo p p 2701 International Lane,Suite 204 608 243-0330 Lic. Establishments <br /> Madison,WI 53704 608 242-6435 fax <br /> www.publichealthmdc.com <br /> Building Permit Review Application <br /> Applicant(owner or Authorized Agent) Chad Gray Phone:608-576 <br /> and Owner(if not applicant) 3565 <br /> Address of Property Owner or <br /> Authorized Agent: <br /> 1/4, 1/4, Section:26 Township:Dunkirk <br /> Location of Property: <br /> Subdivision: Bik , Lot <br /> Parcel Number: 0511-263-8000-4 <br /> Property Address: 375 Hannerville Road <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) ❑ Mound <br /> ❑ At Grade ❑ Inground Pressure ❑ Cesspool <br /> Other(explain):Permit Dane 88-0357 issued 7-29-1988 for 2 bedroom house but system is sized for 3 bedrooms. <br /> Date of POWTS Installation(if known):11-29-1988 Owner at time of Installation: <br /> Size of POWTS:Tank:1000 gallons,Soil Absorption Area:948 Square Feet,Last Pumped: <br /> Age of Existing House: years,Size of Existing House: Square Feet,Number of Bedrooms:3 <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.: Describe Remodeling:. <br /> ❑ Detached Accessory Structure(Specify:Garage,Pole Barn,Shed,etc.): Will there be plumbing?❑Yes❑No <br /> ® Addition <br /> *If addition,what is the size of the addition: sq.ft.,Dimensions: ,Type: <br /> if addition,does the addition contain bedrooms:®Yes❑No If yes,how many: <br /> Total number of bedrooms after addition:3,If addition total number of people using structure/system after addition: <br /> Other:Sanitary Permit aool says 2 bedrooms,but system is actually sized for 3 bedrooms.OK to add 3rd bedroom now. <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 owner or authorized agent is required and indicates the above information is accurate to the best of your knowledge <br /> and indicates the owner's permis 'on is giv= to inspect the p operty for the purpose of this review. <br /> Al ',J� �s� i t_ , �_ -;4N(7; MAr b(€(.2o/`7 <br /> Owner/Authorized Agent .(C0 n 0 < Her</Qj Date <br /> Allow at least two(2)weeks for review to be completed,after required information is received. <br /> 06/08/17-Building Permit Review Application.docx <br />