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<br /> '.0 Public Health
<br /> MADISON &DANE COUNTY Janel Heinrich,MPH,MA,Director
<br /> Healthy people and places Environmental Health Division 608 242-6515
<br /> 2300 5 Park St,Rm 2010 608 242-6435 fax
<br /> Madison,WI 53713 www.publlchealthmdc,com
<br /> Building Permit Review Application
<br /> Applicant(owner or Authorized Agent) ,i Phone: '
<br /> and Owner or not applicant) 'Val t of til� Mit ''01
<br /> Address of Property Owner or �j Ve S i�� `.��4 y •
<br /> Authorized Agent (��rN,� / /4'
<br /> A/6-1/4, 5e-- 1/4, Section: /3 Township: ,j pit.,.?A...—
<br /> Location of Property:
<br /> op rty:
<br /> Subdivision: , Blk , Lot ito
<br /> Parcel Number: "2/0.509434/–*O/64?-434
<br /> Property Address: /6 3 rp o / ,5°I�2 _t7
<br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS):
<br /> Type of POWTS:(check all that apply):
<br /> Jg Septic Tank ❑ Aerobic Treatment Unit, ja. Seepage Bed .
<br /> ❑ Seepage Trench ❑ Seepage Pit(Drywall) ❑ Mound
<br /> ❑ At Grade 0 Inground Pressure ❑ Cesspool
<br /> Other(explain):
<br /> Date of POWTS Installation(if known Owner at ti e of Installation:
<br /> Size of POWTS:Tank: /Oa" gallons,Soil Absorption Area: 4 Square Feet,Last Pumped:
<br /> Age of Existing House: Z 0 years,Size e�of Existing House 11; Square Feet,Number of Bedrooms: 3
<br /> TYPE OF PROPOSED CONSTRUCTION: ASaO le)
<br /> se
<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 /> I' Addition f ' a
<br /> If addition,what is the size of the addition: 721t t, sq.ft.,Dimensions: ,Type:: CL 00
<br /> r
<br /> 'If addition,does the addition contain bedrooms:❑Yes EX,,No If yes,how many: ,
<br /> Total number of bedrooms after addition: ,If addition total number of people using structure/system after addition:
<br /> Other: i"-(4i— 644,,,,„,e.) Dotyi a.. !/J/7"1- ��j� ' ' i I,
<br /> 1 ,dam I%0-001 •.w,
<br /> (POWTS sizing is based on 2 people per bedroom using 75 gallons of water per person per day.) y,/wiz,,, is t+ +ryl
<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.7,--_or authorized age fi5't uired and indicates the above information is accurate to the best of your knowledge
<br /> and in,'' .'s e o er's p lssi i pV5n to inspect the property for the purpose of this review.
<br /> :: (/, :3/12/
<br /> •. = •uthorized Agent Date
<br /> Allow at least two(2)weeks for be completed,after required Information is received.
<br /> Pv : ilIoN A.10.1 311141 it
<br /> 03112118-Building Permit Review Application
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