HomeMy WebLinkAboutTank SpecsDalor 08/05/2013
Sh@t 1 of 1
)@n bv: EMB I
S6le:mrro sdE lchsked by. DFH
ffir,rrRAron
INFILTRATOR SYSTEMS INC.
4 Busine$ Park Rd. Old Saybrook, CT 06475
(8OO\ 2214436
INFILTRATOR IM-1060 TANK
2-COMPARTMENT CONFIGU RATION
LIFTING STMP
(rYP.)B RtsER CONNECTION (TYP.)
A'ACCESS PORT RIM
1.5 [38]
A LID TANK TOP
HALF
CONTINUOUS
ELASTOI\4ETRIC
GASKET
TANK
INTERIOR
TANK
INTERIOR
INLET/
OUTLET
TEE
ALIGNMENT
DOWEL (34)TANK BOTTOM
HALF
SEAM CLIP
(64)
@ wrro-nelcHT sEAM
SECTION DETAIL
BAFFLE SLOT
SECTION B. B'BAFFLE DETAIL
FLEXIBLE RUBBER
GASKET (TYP.)
t1.5801
e*r'erudn
LIFTING LUG
(TYP.)
q 4uo2l
PVC OR ABS
INLET TEE
B'
1 27.o 13,2261 EXTERTOR LENGTH
TOP VIEW
@ plpe PENETRATToN
SECTION DETAIL
o 24.O 1610l ACCESS OPENING
wTH LOCKTNG LtD (2)
a 41021
PVC OR ABS
OUTLET TEE
TANK EXTERIOR
12t.9lt,zzal
c4./ li,Juvl
LENGTH
HIEGHT
END OUTLET
SEAM CLIP
(wP.)
10.21260l FREEBOARD
2]3 TOTAL VOL.1/3 TOTAL VOL.
NOTES:
SECTION A. A'
.I. ALL DRAWING DIMENSIONS IN INCHES IMILLIMETERSI OR AS NOTED,
2. EXTERIOR OF ACCESS OPENING LID INCLUDES THE FOLLOWING WARNING IN
ENGLISH, FRENCH & SPANISH: "DANGER DO NOT ENTER: POISON GASES.'
3, TANK MARKINGS wlLL INCLUDE: MANUFACTURER NAME, MODEL NUMBER,LIQUID
CAPACITY, DATE OF MANUFACTURE, MAXIMUM BURIAL DEPTH, INLET, AND OUTLET
4. MAXMUM BURIAL DEPTH lS 48 in [1,219 mml.
5. MINIMUM BURIAL DEPTH lS 6 in [152 mml.
6. MAXMUM VEHTCLE LOAD tS 4,500-tb I20-kM AXLE LOAD.
7. TANK IS FOR NON.TRAFFIC APPLICATIONS,
8. ATRSPACE tS 16.5%.
9. OUTLET TEE IS COMPATIBLE W|TH EFFLUENT FILTER.
10. INTERIOR LENGTH TO wlDTH RATIO lS 2.3:'l (118.8-INCH INTERIOR LENGTH,
51.7-INCH INTERIOR wlDTH = 2.3).
11. FREE VENT AREA BETWEEN TOP OF BAFFLE WALL AND BOTTOM OF TOP BAFFLE
SLOT lS 39.7 in'.
12. BAFFLE WALL THICKNESS lS 0.31 in [8 mml.
7
S
o
[1,38s1
EXTERIOR
HEIGHT
LIFTING STRAP
(rYP.)
END VIEW
ISOMETRIC
VIEW
SIDE INLET/
OUTLET (TYP.)
11,1 1 81
LIOUID
BAFFLE
SLOT
BAFFLE
*l
3.0
F6l
2[51]X2[51]
FIBERGLASS
SUPPORT
rYP.)
INLET
6.0
Lo t1
BEHIND
BAFFLE
SUPPORT
16.0
[406]
BAFFLE
TOP
O"?,1
BAFFLE
PORT
BAFFLE
SLOT
9D
EST.2('tt
VGISKIJIL. Cl]'EFIATIEINEI E
OWTS (Onsite Wastewater Treatment System) lnspection Report
Prepared For: Jeff Britt (Property Manager) and Geraldine Karetsky (owner)
jdbcarbondale@gmail.com
Address: 2028 CR 108, Carbondale CO 81"623 Garfield County Parcel: 246306200042
Date lnspected: July 18,2025
oBSERVATT O NS/RESU LTS:
July 18, 2025:
We were contacted by the property manager about a sewer backup. Upon arrival, the concrete septic
tank lids were already dug up and the cast iron pipe on the outlet side of the tank was exposed.
Because the concrete lid on the effluent side was seized on, we utilized a jackhammer to remove the
effluent tank lid. Next, we utilized the hydro jetter to clear an obstruction in the section of cast-iron
discharge line and got the tank to drain downstream to the soil treatment area (STA). Once the tank
drained down, we removed a 3 foot section of deteriorated cast-iron pipe and replaced with Schedule
40 pipe and installed a cleanout in order to repair the area and continue our OWTS inspection.
The concrete on effluent side of tank is rotted/deteriorated and we patched with hydraulic mortar as a
temporaryrepair. Thetopofthetankontheeffluentsideisinpoorcondition,notstructurallysound
(top of tank flexes) and is approximately 1-1-.5 inches thick'
The effluent lid of the concrete tank is approximately 50% -75% deteriorated. We covered the effluent
septic tank access hole with a new concrete lid.
The existing 1-000 gallon concrete septic tank is located in the front yard on the east side of the
residence. Garfield County records show final inspection of the originaltank and system components in
April 1992 (see additional documents at end of report). The concrete tank is a single compartment
style (no baffle) with risers and 2 concrete lids for access. Both concrete lids were originally installed
below surface grade.
We utilized video inspection equipment to locate and identify where the cast-iron pipe exits the
residence, transitions to PVC and where the soil treatment area (STA) manifold begins. From Garfield
County records in 1992, the STA is approximately 26 feet long x 24 feet wide and is comprised of
perforated PVC pipe.
HYDRAULIC IOAD TEST: Using a garden hose, we applied 450 gallons of water at a rate of L1 gallons
per minute for 45 minutes down the outlet pipe on the discharge side of septic tank. We utilized video
inspection equipment to confirm that water was dispersing properly through the perforated pipe in the
STA. No backups into the septic tank occurred during the hydraulic load test.
Repair of cast iron pipe existing the concrete septic tank with cleanout in order to continue OWTS inspection.
Replaced the lid on the effluent side of septic tank.
RECOMMENDATIONS:
We propose a tank replacement comprising of a new 1060 gallon lnfiltrator, 2-compartment poly tank
with new risers and lids to surface grade. The new septic tank should be pumped every 3 - 5 years
depending on use and prior to transfer of title. Please see attached lnfiltrator specification sheet.
An effluent bio filter will be installed on the outlet tee inside the new septic tank. This effluent bio
filter should be inspected and cleaned depending on use (refer to manufacture recommendations, or
more often if use patterns indicate).
The existing concrete septic tank will be pumped and abandoned in place. The top and sides of tank
will be crushed into the void and compacted soil will be used to fillthe void.
ln addition, we propose installing an exterior cleanout within 5 feet of the residence.
Approximate location of proposed new tank adjacent to old tank,
exterior cleanout within 5 feet of residence and new sewer service line to the new tank.
o
lnstall an exterior cleanout 5 feet from residence.
*rr i'
-f
f'
,'r
'' "'t
*i*+
.:
t I
t
Approximate location of soil treatment area (26' Lx24'W) consisting of perforated PVC pipe.
PROJECT PLAN:
- Pump concrete septic tank. Excavate to break down the existing concrete tank. Drill holes in the
bottom of tank and prep for abandonment (top and sides of tank will be crushed into the void and
compacted soil will be used to fillthe void).
Excavate in the adjacent area for the new tank. Use the excavated native materials to backfill and
compact the void of the abandoned septic tank.
Excavate and intercept line coming from the residence in order to set grade and dig depth for the new
septic tank. lnstall approximately 20 feet of new sewer line and new exterior cleanout near the
residence.
Set new tank. Begin backfilling with screened rock to the inlet and outlet. Tie in new tank to the
residence.
Schedule inspections with Garfield County Environmental Health'
After inspection, complete backfill and compaction and grading to surface area. Site cleanup.
Send final installation photos and as-built to Garfield County Environmental Health.
Based on what we were able to observe and our experience with onsitb wastewater technology, we submit
this Onsite Wastewater Treatment System lnspection Report based on the present condition of the OWTS.
Voskuil Operations has not been retained to warrant, guarantee, or certify the proper functioning of the entire
system for any period of time in the future. Because of the numerous factors (usage, soil characteristics,
previous failures, etc.) which may affect the proper operation of a wastewater treatment system, this report
shall not be construed as a warranty by our company that the entire system will function properly for any
particular buyer.
q"*LM
Thank you,
Jorden Voskuil, CWP
NAWT lnspector lD: 17085|TC
Voskuil Operations, LLC
PO Box 312 New Castle, CO
970-384-2487
jordenvoskuil @ rocketmail.com
filqPublic'net'" Garfield County, CO
AccountNumber R010156
ParcelNumber 246306200042
Acres 5
Land SqFt 0
TaxArea 010
Mill Levy 74A230
Date geated:9/2!/2Q25
Last Data Uploaded:9/79/2A25 tO:27:2Q PM
Physical Address 2O28 108 COUNTY RD
CARBONDALE 81623
OwnerAddress KARETSKY GERALDINE K
1660SILVER KING DRIVE
ASPEN CO 81611
Overview
Legend
l_".l Parcels
Roads
Parcel/Account
Numbers
Owner Name
i Lakes&Rivers
- CountyBoundary
Line
TotalActualValue $0 Last2Sales
Date Price
7/3/1992 $180,000
nla $
Develooed bvt?SCH N EI DER
GEOSPATIAL
9121125, 1:24 PM
Garfield County, CO
Summary
Account
Parcel
Property Address
Legal Description
Acres
Land SqFt
Tax Area
MillLevy
Subdivision
qPublic - Garfield County, CO - Property Record Card: R01 0156
R010156
246306200042
2028 108 COUNry RD CARBONDALE,CO 81-623
Section: 6 Township: 8 Range: 88 TR lN N1/2 5.36 ACRES
5.36
0
10
74.4230
View Map
Map
Owner
KARETSKY, GERALDINE K
1660 SILVER KING DRIVE
ASPEN CO 81611
Land
UnitType
Square Feet
Acres
Buildings
SINGLE FAM.RES.-LAND - 1112 (RESIDENTIAL PROPERTY)
0
5.36
Building #
Units
BuildingType
Abstract Codes / (Property Typel
Architectural Style
Stories
Frame
Actual Year Built
Gross LivingArea
Total Heated SqFt
Bedrooms
Baths
Heating Fuel
HeatingType
Air Condltloning
RoofType
Roof Cover
7
I
SFR
SINGLE FAM,RES-IMPROVEMTS-1212 (RESIDENTIAL PROPERTY)
1.5TORY
!
WOODFMME
1982
2,O34
2,O34
a
2.5
GA5
FORCEDAIR
NONE
GABLE
PREFAB MET
https://qpublic.schneidercorp.com/Application.aspx?ApplD=1038&LayerlD=22381&PageTypelD=4&PagelD=9447&Q=1512550479&Keyvalue=R010156 114
9121125: 1:24 PM qPublic - Garfield County, CO - Property Record Card: R010156
Building #
Units
BuildingType
Abstract Codes / (Property Type)
Architectural Style
Stories
Frame
Actual Year Built
Gross LivingArea
Total Heated SqFt
Bedrooms
Baths
Heating Fuel
HeatingType
Air Conditioning
RoofType
Roof Cover
Actual Values
Tax Year
2
1
5FR
SINGLE FAM.RES-IM PROVEMTS-1212 (RESIDENTIAL PROPERry)
I 1/2 STRY
WOOD FRAME
1983
1,644
7,644
2
GAS
FORCEDAIR
NONE
GABLE
COMP SHNGL
2025 2024
Actual Value
Assessed Values
$1,778,8s0.00 $1,s02,660.00
TaxYear 2025 2024 2023 2022 2027
Non School Assessed Value $111,180.00 n/a n/a n/a n/a
School Assessed Value $725,4!O.0O n/a n/a n/a n/a
Pre 2025 Assessed Value n/a $100,670.00 $100,670.00 $71,810.00 $73,870.00
.House Bill 248-1001 established a separate assessment rate for school district residential properties, effective for the 2025 tax year and beyond. Click here for Assessor
FAQs
Mill Levies
Tax Year 2025 2024 2023 2022 2027
Non School District Levy 3r.277 n/a n/a n/a n/a
School District Levy 43.152 nla n/a nla n/a
Total Levy
Tax History
74.423 74.423 72.5L8 87.025
2024
79.74
2023Tax Year
Taxes Billed
Click here to view tlre tax information for this oarcel on the Garfield Countv Treasurer's website.
Transfers
seleDate DeedTvpe
$7,492.76 $7,300.40
9/30/1992 SPECIALWARRANTY DEED
r/3/7992 PUBLIC TRUSTEES CERT RED
tl3/7992 WARRANry DEED
L/2/79?2 PERSONAL REP DEED
9/r1-tr99r PUBLIC TRUSTEES CERT
9/71-/r99r PUBLIC TRUSTEES CERT
t2/2/7986 PERSONAL REP DEED
9/30/7982 MEMORANDUM
9/27/1982 RFSOLUTION
Property Related Public Documents
Click here to view Prooertv Related Public Documents
Photos
https://qpublic.schneidercorp.com/Application.aspx?ApplD=1038&LayerlD=22381&PageTypelD=4&PagelD=9447&Q=1512550479&KeyValue=R010156 214
9121125, 1:24 PM qPublic - Garfield County, CO - Property Record Card: R010156
7'
hf)
30'
ONE
1980 sf
50H 18.0 7xf\,o:1,:7
7
m
t?
14'
.>
WOOD BALCONY
934.0 sf
https:i/qpublic.schneidercorp.com/Application.aspx?ApplD=1038&LayerlD=22381&PageTypelD=4&PagelD= 9447&Q=1512550479&KeyValue=R0'l 0156 314
9121125,1:24PM qPublic - Garfield County, CO - Propefu Record Card: R010156
:{
+N
FSg
5ru sl
?H
:rl
th., a-::.,rit)li) Cr\.t) tt.i ,tiett.). t iliit< x 'tai:*:' ::'tr:('/ ,:i{'iai' T.i) a)(;'it:ica tht ti.)it aiL':\)i2i.t
t tf.J:-ai\1.::tt1 t.i1; r illii. fi.) :: ai- (;ifili,:a a^rf a"t{)A t irtglied zrt 2r';','r alea: i':a i:1e fl, l:' !1'::r':tr :t 1
\)ti:::.:;lreri:arlaji\tr).i.)aa'.)ii;i!itla:cttilCajnsiiilt(-1")('2...e)1i:il:tcxu:ti::,ar.li:.t:n)l': -tiia':5
: l r., t'a,:: j -- .
I User Privacv PolicY i GDPR Privacv Notice
Last Data up.pss!;!lffQ!!8:27:p-$v!
iurriaa! !a Li.,r.,i.f,pc,.i trv
B scHruetoen
tlg2.g ef
3S
$gfrHFffiY F
oltaH
3&4.fl s{
olrE3&*.0:l
+
3S
lrr€€g sAlcollY
804.0 rf
https://qpublic.schneidercorp.com/Application.aspx?ApplD=1038&LayerlD=22381&PageTypelD=4&PagelD=9447&Q=1512550479&KeyValue=R010156 414
Dabr Oa/O5/2O13
Sheel 1 of 1lhecked by DFH
)rMbyr EMB
icnle: Nor rc sc[E
ffir,rrRAroft
INFILTRATOR SYSTEIVIS INC.
4 Business Park Rd. Old Saybrook, CT 06475
(800) 221-4436
INFILTRATOR IM-1060 TANK
2-COMPARTMENT CONFIGURATION
B
AA
LIFTING STMP
(rYP.)RtsER CONNECTION (TYP.)
1.5 t38l
ACCESS PORT RII\4
TANK
INTERIOR
TANK
INTERIOR
INLET/
OUILET
TEE
ALIGNMENT
DOWEL (34)TANK BOTTOM
HALF
TANK TOP
HALF
CONTINUOUS
ELASTOMETRIC
GASKET
SEAM CUP
(64)
@ mlo-nercHT sEAM
SECTION DETAIL
BAFFI.E SLOT
SECTION B. B'BAFFLE DETAIL
LID
54.7
FLEXIBLE RUBBER
GASKET CIYP.)
[1,5801
EXTERIOR
B'
127 .O 13,2261EXTERTOR LENGTH
TOP VIEW
@ plpe PENETRATToN
SECTION DETAILLIFTING LUG
(rYP.)
a 4u021
PVC OR ABS
INLET TEE
s 24.0 [610lACCESS OPENING
wrH LocKtNG LID (2)
1O.21260l FREEBOARD q 41021
PVC OR ABS
OUTLET TEE
WALL
TANK EXTERIOR
12t.O Is,tzbl
52.2 l1,55(
LENGTH
WDTH
END OUTLET
SEAM CLIP
(rYP,)
s
o
[1,3891
EXTERIOR
HEIGHT
LIFTING STRAP
('r /P.)2/3 TOTAL VOL./3 TOTAL VOL.
SECTION A.A'
NOTES:
1. ALL DRAWING DIMENSIONS IN INCHES IMILLIMETERSI OR AS NOTED.
2. EXTERIOR OF ACCESS OPENING LID INCLUDES THE FOLLOWNG WARNING IN
ENGLISH, FRENCH & SPANISH: "DANGER DO NOT ENTER: POISON GASES."
3. TANK MARKINGS \MLL INCLUDE: MANUFACTURER NAME, MODEL NUMBER,LIQUID
CAPACITY, DATE OF MANUFACTURE, MAXIMUM BURIAL DEPTH, INLET, AND OUTLET
4. MAXMUM BURIAL DEPTH IS /A in [1,219 mml.
5. MINIMUM BURIAL DEPTH lS 6 in [152 mml.
6. MAXMUM VEHTCLE LOAD tS 4,500-tb [20-kNl AXLE LOAD.
7. TANK IS FOR NON-TRAFFIC APPLICATIONS.
8. ATRSPACE tS't6.5%.
9. OUTLET TEE IS COMPATIBLE WITH EFFLUENT FILTER.
10. INTERIOR LENGTH TO WDTH RATIO lS 2.3:1 (118.8-INCH INTERIOR LENGTH,
51.7-INCH INTERIORWIDTH = 2.3).
11. FREE VENT AREA BETWEEN TOP OF BAFFLE WALL AND BOTTOM OF TOP BAFFLE
SLOT lS 39.7 int.
12. BAFFLE WALL THIGKNESS lS 0.31 in [8 mml.
END VIEW
ISOMETRIC
VIEW
SIDE INLET/
OUTLET (TYP.)
*l
16l
44.0
11,1 1 81
LIOUID
DEPTH
BAFFLE
SLOT
BAFFLE
2l5UX2[51]
FIBERGLASS
SUPPORT
(rYP.)
6.0
l-Ot4061
-1BEHIND
BAFFLE
SUPPORT
BAFFLE
TOP
O,,?,1
BAFFLE
PORT
BAFFLE
SLOT
I {"lfi",} ,r;ii;!ir6t#rs."'1t'tefrf*0HDrurt*I',t4nFt*-F r?E*rw;-SW}-.;-Tff a-,,t.---."r-;d
II*
I
ti
,t'
,r
- rrudrvrouAL sEwAGE DlsPosAL PERMIT Ng '1000
i'.
CARF|FLD COUNTY BUlLOlt{O AND SANITATION DEPARTTEilT
log 8lh $ttUt SulL !0i'
qbnwood qiltgt Gobndo Oltol
Phom (t0lll e{5{tr2
Thls doga ngl conttlluto
I bulUino or use p€fi{t
3or1 t$rstekyOwner
2028 C.R. [08r Cerbondela$rtcm Locrtion
Solth EncgrprlletLlccnscd lnrtaller
' Conditionsl Gonstrucion rpproval ir herebY grtnted for !
-2-- Septic Trnk or -- Aerated treatlnont unit'
Abrorption lr:ea lot dirper:al arsal computed as follows:
perc rats ol one incfi ,n ,//i -minutos
Therefore the no. of bedrooms - ? - x
Mty tr! tuggPtt:
,.olifitir'nimom ol "i 3. " . sq. tt' of absorption erst per bedroom.
,4 )t'l ,c,!t. minimum requiremont - ! total ot '/; '/ / sq. ft. of rbtorption lrel.
' )'4 ,s gollon
I
:
!:
!.
tF
;tr
,:
t
Drte lnrpoctor
FINAL APPROVAL OF SYSTEM:
No ryrtem rhall be deemed to be in compliance with th€ sewage Dicposst Laws until the asrembled ry3t€m is rpprovod prior tocover'
ing rny part.
itt;;t'.lAL-
i\ r, '!tr ' I
Eeptic Tank access for inspection and cleaning within 1 2" of ground rurlece or t€rrt€d 8cc€rt ports ebove ground
gurface.
Proper materirls and assemblv.
Trlde name ol reptic tank or serated treltment unit'
Adoguste ob,sorption (or dispersatl area. Jt1 t 2 6
Adeguate compliance with permit requir€ments.
Adeguale compliance wirh CountV and $tate regrilations/requirements'
Other
I
Dato
'coNDtTt
2.
lnspector
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
;lr
t'
t
t'_;.
g.',
INDTVIDUAL SEI'IAGE D
I
GI'INER
test holes, soil pro files in test holes
E0 FACILITY: County
of Town
ll S PLICATI
Appl ica tfon
Approva lbv
0fflcla'l :
. (See page^4
lLptirt.!
County
I {r''o
tSize *{ac,
ADDRESS PHONE
CONTRACTOR
AI}DRESS I}HONE ?o.s- arsE
PERl4rT REQUEST FoR ( 2,fNew Instal'lation ( )Alteratjon ( )Repalr
Attach separate sheets or rePor t shovting entire area wlth resPec t.to surroundlng areas'
topography of area,habitable build ing,'locatlon of Potable wate r wells, soil percolatlon
)
Near what Clty
Legal Descrlptl
I.IASTES TYPE:( {} Dwellins
( ) Cormercial or Institutional
( ) Transient Use
( ) l{on-domestic Wastes
()Other - Describe
BUILDING OR SERVICE TYPE:?.-*,--,-^rJ: al
Number of bedrooms of persons At+
(/x) GarUage grinder (x) Automatic washer (X) D{shwasher
SOURCE AND TYPE OF I.IATER SUPPLY:(;)well ( )sPrlng ( )streamorcreek
Gtve depth of all wells wlthln 180 feet of system:
If supplled by cormunlty water, give name or suppl
GRTXJNQ C0NQI.[,IONl:
ier: nf *-
t)^b tA a c-J ,-\Oepth to bedrock:
Depth to flrst Ground llater Table:Ou)
Percent ground sIoPe:a; F/a-f
DISTANCE TO NEAREST COI.II"IUNITY SEI.IER SYSTEM:
llas an effort made to connect to comlunity system?Q
TYPE OF INDIVIDUAL SEI{AGE DISPOSAL SYSTEII PROPOSED:
(x) Septlc Tank
( ) Vault Prlvy
( ) Plt Prlvy
( ) Cnemlcal Tollet
FINAL D ISPOSAL BY:
K) eototptlon Trench, Bed or Pit
) Underground DlsPersal
) Above Ground DisPersal
) Aeration Plant
) Composting Tollet
) Inclneration Toilet
( ) Vault
( ) Recycllng, Potable use
( ) Recycllng, other use
(
(
(
(
(
(
(
(
) 0ther - Describe: ..
( ) Evapotransplration
( ) Sand Filter
( ) llastewater Pond
) 0ther - Describe:
I^IILL EFFLUENT BE DISCIIARGED DIRECTLY INTO WATERS OF T}IE STATE? NO
, t.a , ,
,ioit-.'pEic0LATI0N TEST RESULTS: (To be conrpleted by Registered Professlonal Engineer.)
14l nutes
l4l nut es
per lnch in hole l{o. 1 Minutes per lnch in hole llo. 3
per inch in hole No. 2 Minutes per inch ln hole No.-
Nante, address and telephone of RPE who ntade soil absorption tests
Narne, address and telephone of RPE responsible for deslgn of the system:
App
fur
llcant acknow'ledges that the completeness of the app lication is conditlonal upon such
department to be the appl ican
be re
the
qul
loc
red by the local healthal heal r.h department forther mandatory and additional tests and reports as maytorby
purposes of
SUCh terms a
cationi and the lssua nce of the perrrrflt. JB 'subJect to
adopted under Article 10, Tltle 25,
nd condltlons as deemed necessar v
97
to lnSure compllance with rules and regulat
3, as amended.
lons
c.R.s. 1 The underslgned hereby cert lfles
lnfornation a nd repor ts submitted herewith and requlred to be
are or w ill be repre
deslgned to
of issuing
representati
sented to be true and correct to the best
and are be relied on by the local .dePartnent of health
the permit appl ied for herein. I further under-
on ma y result I n the denial of the a atlon
tg ranted based upon sald aPPl ic and in I I act{on per-
Date 5i gned
PLEASE DRAltl AND ACCURATE MAP TO Y R PROPERTY ov trR
the e
made and furnlshed bY
valuation of the appll
that all statements made,
submltted by the appllcant
of my knowledge and belief
ln evaluatlng the same for
stand that any falsiflcati
or revocatlon of any permi
Jury as provlded by law.
purposes
on or mls ppl lc
for
-
'",j,' 'r.l..r
rt.r1r.l 3
?t
.ABr
Itx:o 3 *l
$\
't
I
1
- cAteL
Iil
I
P!9r-,PLAI{ At{p .pFSIGN .FFATUIFS :
lnclude by measured dlstance location of wells, springsr potable uater supply
llnes, cliterns, bulldings, property lines, subsoil drains, lake, water course,
stream, dry gulch and show location of proposed system by dlrection and distance
from dwelllng or other flxed reference obJect, and additional submlssions in
support of thls application such as data, plans, specificatlons, statements and
conrnl tments.
Fage 4
I
t I
%
3,
4fiN IJ