Laserfiche WebLink
f <br /> aood <br /> = 'e Public Health <br /> MADISON Sr DANE COUNTY Janel Heinrich,MPH,MA,Director <br /> Heat people and faces Environmental Health Division 608 242-6515 Well&Septic <br /> 2701 International Lane,Suite 204 608 243-0330 Lk.Establishments <br /> Madison,WI 53704 608 242-6435 fax <br /> www.publichealthmdc.com <br /> Building Permit Review Application <br /> Applicant Kevin Kortim Phone:608-212- <br /> 1872 <br /> and Owner tt not apva.q <br /> Authorized�Owner or kevini`orth r <br /> g.co <br /> SE 1/4. NW 1/4, Section:34 Township:Christiana <br /> Location of Property: <br /> Subdivision: , Bic Lot <br /> Parcel Number: 0612-342-9580-1 <br /> Property Address: 1746 STH 73 e'(/ <br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS): f 1I r -' f"6 3 <br /> Type of POWTS:(check all that apply): •ris Ee 3'_Z t-f9?1f <br /> O Septic Tank ❑ Aerobic Treatment Unit Bed i 3( <br /> ❑ Seepage Trench ❑ Seepage Pit(Drywall) ❑ Mound 9.-f 1301 <br /> ❑ At Grade ❑ Inground Pressure ❑ Cesspool <br /> Other(explain): 1 =_,•u•�.. •, uir ar: � a:_! <br /> Date of POWTS installation(V Imow t):3-22-1974 Owner at time of installation: <br /> Size of POWTS:Ta ilc 1000 salon gallons,Soli Absorption Area:990 Sa.FL 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 /> ® <br /> Remodeling If remodeling,how many Sq.FL: Describe Remodeling:. <br /> ❑ Detached Accessory Structure(Specify Garage,Pole Barn,Shed,etc.): viii,there be plumbing?❑Yes❑No <br /> ® <br /> AddlUon <br /> •ft addition,what is the size of the addition: sq.ft.,Dimensions: .Type: <br /> *if addition,does the addition contain bedrooms:0 Yes❑No If yes,how many:1 <br /> Total number of bedrooms after additlon:A,if addition total number of people using structure/system after addition:Maxitmm of <br /> 6 <br /> Other: s.b. ?,.'_ it .u't s�•..-.,� •__>_�• <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 dinensioned showing lot ines,well(s),existing POWTS and <br /> POWTS replacement area Of known),all existing structure(s),propOSed construction(dotted lines,or dearly 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 falling POWTS will be ordered <br /> corrected. <br /> Signature of owner or authorized agent Is required and indicates the above informsUon is accurate to the best of your knowledge <br /> and indicates the owner's permission is given inspect the property for the purpose of review. <br /> knowledge <br /> Italia ire AP'i D& !ice /(t-coyCRKG. cif P" 'ff <br /> Owner/AutirorizedAgent < _ ,r,W1►'(/igM,r Det73/ "/ p/7 <br /> Allow at least two(2)weeks for review to be completed,after required information is received. ( (( <br /> oe124/17-e,rdln.pen Appt aocx • <br />