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'• •.' Public Health MADISON lot DANE COUNTY lanel Heinrich,MPH,MA,Director Heal(y{,,'people and places Environmental Health Division 608 242-6515 � p 2300 S Park St,Rm 2010 608 242-6435 fax Madison,WI 53713 www.publichealthmdc.com Building Permit Review Application Applicant(owner m Aulho hued Agent) Jon&Bobbi Petersen Phone: and Owner not applicant) Address of Property Owner or 5867 Cty Hwy CV Authorized Agent NW 1/4, SW 1/4, Section:8 Township:Burke Location of Property: Subdivision: , Bik Lot Parcel Number. 0810/081/9200/6 Property Address: 5867 Cty Hwy CV EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS): Type of POWTS:(check all that apply): O Septic Tank ❑ Aerobic Treatment Unit ❑ Seepage Bed ❑ Seepage Trench ❑ Seepage Pit(Drywell) ❑ Mound ® At Grade ❑ Inground Pressure ❑ Cesspool Other(explain): Date of POWTS Installation(if known):12/21/1999 Owner at time of installation:LaVonne Hall Size of POWTS:Tank:100/650 gallons,Soil Absorption Area:1125 Square Feet,Last Pumped:07/31/2015 Age of Existing House: years,Size of Existing House: Square Feet,Number of Bedrooms:3 TYPE OF PROPOSED CONSTRUCTION: ❑ New Structure ❑ Replacement Structure(Fire,Tornado,Flood,Mobile Home Replacement,etc.): ❑ Remodeling If remodeling,how many Sq.FL: Describe Remodeling:. ❑ Detached Accessory Structure(Specify:Garage,Pole Barn,Shed,etc.): Will there be plumbing?❑Yes❑No O Addition `if addition,what is the size of the addition: sq.ft.,Dimensions: ,Type: if addition,does the addition contain bedrooms:❑Yes 0 No If yes,how many: Total number of bedrooms after addition:1,if addition total number of people using structure/system after addition: Other., (POWTS sizing is based on 2 people per bedroom using 75 gallons of water per person per day.) PLOT PLAN: Provide a drawing of your property drawn to scale or adequately dimensioned showing lot lines,well(s),existing POWTS and POWTS replacement area(if known),all existing structure(s),proposed construction(dotted lines,or clearly labeled)and distances between above. If a POWTS is found to be a cesspool or is found discharging onto the surface of the ground or into ground water,surface water,or bedrock on the above property,this will be considered POWTS failure and the failing POWTS will be ordered corrected. Signature of owner or authorized agent is required and indicates the above information is accurate to the best of your knowledge and indicates the owner's permission is given to inspect the property for the purpose of this review. Owner/Authorized Agent Date Allow at least two(2)weeks for review to be completed,after required information is received.