HomeMy WebLinkAbout03319 INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER V •
ADDRESS 5'4'S7 , �SGS+%ac Awe tel �1 <94 PHONE 9.37 — .3s-9V74
CONTRACTOR 5,944
ADDRESS PHONE
PERMIT REQUEST FOR X NEW 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 /4,69e =1/ - c Size of Lot 76 Ac 2OS
Legal Description or Address % ✓Nsao RS % W r - e 6 O4 sfie 2 : •�'!s h 2
WASTES TYPE: (X) DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON - DOMESTIC WASTES
( ) OTHER - DESCRIBE `) Q� n� -- BUILDING OR SERVICE TYPE:_ S'& 1- ✓ I�WC JCX
Number of Bedrooms 3 / Number of Persons z
(}Q Garbage Grinder ) Automatic Washer ()() Dishwasher
SO1 JRCE AND TYPE OF WATER SI JPPLY: (Xi WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM:
Was an effort made to connect to the Community System?
' • I _' s • a 1 ,.' s • t , lit h i . , : in . MINIMIJM 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 to Property Lines: 10 feet
Ye ' I II!! • • EDI PI •L Y EMP ' I WIL NITBEI J_D
WITHOUT A SITE PLAN.
GROIIND CONDITIONS:
Depth to first Ground Water Table
Percent Ground Slope
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TYPE 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
FINAL DISPOSAL BY:
o ') 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? /Vo
PERCOLATION TF.ST REST JI,TS: (To be completed by Registered Professional Engineer, if the Engineer does
the Percolation Test)
Minutes per inch in hole No. 1 Minutes per inch in hole NO. 3
Minutes per inch in hole No. 2 Minutes per inch in hole NO. _
Name, address and telephone ofRPE who made soil absorption tests:
Name, address and telephone of RPE responsible for design of the system:
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 evaluating 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 revocation of any
permit granted based upon said application and in al action for perjury as provided by law.
Signed C Date V00
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
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