HomeMy WebLinkAbout03574 INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION •
OWNER errcd /cr ccn✓N
ADDRESS 'i 9 Coccn* y ,0 s SAS PHONE 9S -3 9
CONTRACTOR
ADDRESS PHONE
PERMIT REQUEST FOR ( ) NEW INSTALLATION ( ) ALTERATION AIR
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 f)/e .7 rat s F / r__ Size of Lot res
Legal Description or Address 4 ? 7 <'7)//Pi. a9S Py4 rn -5rt 40///, s h
WASTES TYPE: (' DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON - DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE:
Number of Bedrooms Number of Persons
(t4Garbage Grinder (Automatic Washer WTI washer
SOURCE AND TYPE OF WATER SUPPLY: ( ) WELL ( ) SPRING ( ) STREAM OR CREEK n
If supplied by Community Water, give name of supplier: /"i t t/ f e / /
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: /2,n9
Was an effort made to connect to the Community System? AV,4
A site elan 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 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
Percent Ground Slope
2
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