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INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION Bi -.)
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OWNER CEJ r ff)( -
ADDRESS Z z t ', {2S0x 1 ST.U E
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114 CONTRACTOR 4 ycEmeikv b Off $ ( r
ADDRESS b fZ11-lt'vOC P6 .!`1 i••' PHONE i - ` y7 - J
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PERMIT REQUEST FOR VEW INSTALLATION ( } ALTERATION ( ) REPAIR
Attach separate sheets or report showing entire area with respect to surrounding areas, topography of area, habitable
building, location of potable water wells, soil percolation test holes, soil profiles in test holes (See page 4).
LOCATION OF PROPOSED FACILITY:
Near what City of Town C, R's 01VriitLe Size of Lot _ tk Ce.i
Legal Description or Address LoT 3, cos # r . Ne f Std. J u 1S/ a
WASTES TYPE: I><DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( ) OTHER DESCRIBE
BUILDING OR SERVICE TYPE:
Number of Bedrooms
Number of Persons_- 1
Garbage Grinder ,(Automatic Washer (dishwasher
SOURCE AND TYPE OF WATER SUPPLY: (WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:J`LeLC
Was an effort made to connect to the Community System?
A site plan is required to be submitted that indicates the following MINIMUM distances:
Leach Field to Well: 100 feet
Septic Tank to Well: 50 feet
Leach Field to Irrigation Ditches, Stream or Water Course: 50 feet
Septic System (septic tank & disposal field) to Property Lines: 10 feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT
A SITE PLAN.
GROUND CONDITIONS:
Depth to first Ground Water Table r'0N e FoupLO
Percent Ground Slope ' 9
2
TYP OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
( SEPTIC TANK ( ) AERATION PLANT ( ) VAULT
( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POTABLE USE
( ) PIT PRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
( ) CHEMICAL TOILET( ) OTHER -DESCRIBE
FIN. L DISPOSAL BY:
ABSORPTION TRENCH, BED OR PIT ( ) EVAPOTRANSPIRATION
( ) UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
( ) OTHER -DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE?.
PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, if the Engineer does the
Percolation Test) ..cee "CG 1 e '
Minutes per inch in hole No. 1
Minutes per inch in hole No. 2
Minutes per inch in hole No. 3
per inch in hole No.
Minutes
Name, address and telephone of RPE who made soil absorption tests:
CD
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Name, address and telephone of RPE responsible for design of the system: S / i ' , -1 / a e
Applicant acknowledges that the completeness of the application is conditional upon such further mandatory and additional tests and reports as
may be required by the local health department to be made and furnished by the applicant or by the local health department for purposed of the
evaluation of the application; and the issuance of the permit is subject to such terms and conditions as deemed necessary to insure compliance
with rules and regulations made, information and reports submitted herewith and required to be submitted by the applicant are or will be
represented to be true and correct to the best of my knowledge and belief and are designed to be relied on by the local department of health in
evaluatin g the same for purposes of issuing the permit applied for herein. I further understand that any falsification or misrepresentation may
result in the denial of the application or revoc of any permit granted based upon said application and in legal action for perjury as provided
by law.
Signed
Date
tu7
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!