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• • Jane'NeinkFt,MPH,MA,Director <br /> " <br /> Public Health Environmental Health Dion <br /> 2300 S P-ark Rrn 2010 I308 242-G5 <br /> Stitt 2424435 fax <br /> MADISON DANF COUNTY Madison.VII 53713 mew PibliChealturoic.cm <br /> Healthy people and places Building Permit Review Application <br /> AF13-- kont Aieut.wo Noire, -- , <br /> and Owner to nil LSA-1110 tAk 115: ..;\ ivi3.sjyr <br /> Address of Property Curiae or J <br /> Au“IfInFed Agent. <br /> )41j1, f 171u., <br /> co'f 14, S IA) svaion. c,) Towrtauplafittos. <br /> I LoGatten of Prupeny. . <br /> Stiodiviston- Rik Lot <br /> Parcel humber- <br /> Property AddresS IL 3 / cô oc13 - 3 421'60 tiata Dr• c <br /> Ike 3.141 <br /> EXISTING NOUSE ARO PRIVATE ONSTTE WASTEWATER TREATMENT SYSTEM(POWTSI: <br /> Type of POWYS-(check an Mat aorktr)- <br /> P. Septic 1ik 0 Aerobic Treatment Unit 0 Seepage lied <br /> o SeePage Trench 0 Setbafle (DrYerenl 0 Mound <br /> O At Grade 0 ingroun0 Nessus* 0 Cesspool <br /> Other(expeael) <br /> Date of PONT 5 Installation knowny Chime at time of Instanason- <br /> Sze of POWTS.Twit. I oCA. ganord Snit Absorptem Area. Square Feat.last Pumped II ' <br /> Age or kriging House. i S' years Size of Existing to . a?,IOC/Square Imsl.Number of Bedrooms. <br /> TYPE OF PROPOSED CONSTRUCTION: <br /> O New Smocbote 0 Heplaccrnent Sbucture(nue Tornado,Flood,Mobile Home Neplacemeill.etc.). <br /> g Remodeling If renicelelm how many Sq II• se/a Desabe RemodeIng• {1) Z; Seet.. C.r% 41. <br /> O Detached Accessory Structure(Specify.Garage Pole Ram,Shed.etc) IMO there be pturnongT 0 ens 0 No kir;iv <br /> Addmon .Y141 pfeteFr <br /> tb <br /> 'If acideon what is the we of tw addition. sq.t,Dimensions If fR/1 ,Type- 11 .0i7/1.517I5 let ben "Urotry, <br /> if addbon,does the season contan bedrooms.El Yes 10 No If yes how many <br /> Toter number of bedrooms alter additIOn lick:WO)told number of people u$v siruclorefItYshorn after addIIIFFI' <br /> Other. <br /> IPOWTS Wing is based on 7 people per bedrocrri mitt 75 gallons of water per person per day <br /> PLOT PLAN <br /> Prow%a crewing or your property erasen to scale or adequately dimensioned shoeing tot lines.we(s),emstng POWT5 and <br /> POWT replacement area known',at miming soucsure(s),proposed construCtion(dotted lines,or dearly Whetted)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 prOpefty,this will be considered POWTS who*and the failing POWTS will be ordered <br /> corrected. <br /> SiretUre of owner or ante:rime agent is required ard mdocafes the above information is accurate to kw bell of your lino/ledge <br /> and indicates the owners permission is grAsn to inspect the;rowdy for the turpose of trid rmAow <br /> Ceinerntualorowel Agent bare <br /> Mow at least two(2)wools or review to be oarnpreteo aber regured ntonnallan is l'IMANwea <br /> 42.4.o."Vietni%4 tyr*Apprical on 010 <br />