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•.• °" Public Health
<br /> MADISON & DANE COUNTY lane) Heinrich, MPH, MA, Director
<br /> Healthy people and places Environmental Health Division 608 242-6515
<br /> 2300 S Park St, Rm 2010 608 242-6435 fax
<br /> Madison,WI 53713 www.publichealthmdc.com
<br /> 237q / �d�( Building Permit Review Application
<br /> Applicant(Owner or Authorized Agent) ��//9 J Phone: ��� ^�n`�J�
<br /> and Owner(if not applicant) / 7.to A J 11-/
<br /> Address of Property Owner or 1
<br /> Authorized Agent:
<br /> f ,5 v 1/4, .5 �/1/4, Section I /C Township:
<br /> Location of Property: / / v1
<br /> ` a Subdivision: Blk Lot
<br /> Parcel Number: 0 6)/' --- / 4 ,5 .` 3 70.i /d ? P 0 A/Ai
<br /> Property Address: ;,( 3 7 , /(1 / ,f . A( frid fr/ a O
<br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS):
<br /> Type of POWTS:(check all that apply):
<br /> Peptic Tank f / ❑ Aerobic Treatment Unit
<br /> Seepage Trench C2%)S f r7, ❑ Seepage Pit(Drywell) ❑ Mound
<br /> ❑ At Grade ,. O❑ In round Pressure ❑ Cesspool
<br /> Other(explain): r J'AI'rl� co-' 2'Z c/ Ao( 7Z°
<br /> Date of POWTS Installation(if known): 8 -41-SP-4— 2°d° Owner at time of Installation: )c €c-C
<br /> Size of POWTS:Tank: (000 gallons,Soil Absorption Area: '750 Square Feet,Last Pumped:
<br /> Age of Existing House: years,Size of Existing House: Square Feet,Number of Bedrooms:
<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:El-Yes❑No If yes,how many: ( ,
<br /> Total number of bedrooms after addition: Z---, If addition total number of people using structure/system after addition: .
<br /> Other: - /? L r/fr:614A /.� .1(�C, y gr-vo,,e ,'A-/
<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 o wner or authorize; -gt nt is -quired and indicates the above information is accurate to the best of your knowledge
<br /> and•. ti the owner's per i Sion i v o inspect the//property for the purpose of this review.
<br /> Owner/Authorized Agent D(‘/%(
<br /> to
<br /> Allow at least two(2)weeks for review to be comp d,a requi d Information is received.
<br /> Arne°0 C 44/1Q--( 1.4\1( iltef/41/f
<br /> 06/21/17-Building Permit Review Applicalion.doc 6Z 4(c._ a (1 ---M.D(gx,,v ( ,� e �{/ '/f
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