HomeMy WebLinkAbout03621 PYPE QI 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
:INAL DISPOSAL BY:
XJ ABSORPTION TRENCH, BED OR PIT ( ) EVAPOTRANSPIRATION
UNDERGROUND DISPERSAL ( ) SAND FILTER
ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
OTHER - DESCRIBE j e,' fi a td rs
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? Nv
?ERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, if the Engineer does the
?ercolation 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. _
game, address and telephone of RPE who made soil absorption tests:
game, address and telephone of RPE responsible for design of the system:
\pplicant 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
)r by the local health department for purposed of the evaluation of the application; and the issuance of the permit is
.ubject to such terms and conditions as deemed necessary to insure compliance with rules and regulations made,
nformation and reports submitted herewith and required to be submitted by the applicant are or will be represented to
)e true and correct to the best of my knowledge and belief and are designed to be relied on by the local department of
tealth in evaluating the same for purposes of issuing the permit applied for herein. I further understand that any
alsification or misrepresentation may result in the denial of the application or revocation of any permit granted based
tpon said application and in legal action for perjury as provided by law.
igned /2fl La Date 14 -7 I ' O (
LEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY!!
3