HomeMy WebLinkAboutSEP1971-00120SEMI- 00)2-
CLYNTTC HrAT-TH f)Tq7j -rol,ql
C*UA House, Port To
Carcline Pernit No.
rowt
Fee Paid S
SLIWAGE DISPOSAL PERMIT APPLICATION
Submit in Duplicate
ADDRESS
;-�—�;,DATFi
6
80 fiRe is co ono
DIRECT16NS 'F&PATING SITE
APPLICATION is HEREBY MADE TO: INSUU NEW - SYSTEM
REPAT-R EMT13G
E OF BUILDING 00, Or BEDROOMS
AAT M"" -nim- ---- . ---. -
BASEMENT SITE ST NAME OF INSTALLER
n-7
2. Location of bu3ldag 8o
3-.. Location of septic tank 9•
4, ---Location of drainfield 10.
.%. Slope of land 3.14
6,-Wa-ter lines & well(if applicable) 12.
Pere. No,
-
Pert.. NO a
Perc. No.
Dki -ve w-av S , ".patios car I P0rt#*dtc*,-
Streams or bodies of water nearby
Location of percolation test holes
Septic tank size /-?- el j�2 .,gall='
Length of propose-d-,draeld
Depth to water if encountered.
PERCOLATION TEST RESULTS
Pepth Time ;eq7ired to TPercolation rate
of hole seep last 6 in. J(divide time bjyQ
DRAINFIELD LENGTH -.WIDTH DEPTH No. OF 1ans�.
IT - ZS- = REBY AGREED THAT HE PROPOSED- INSTALLAT BE MADE WIN 2 NE L)
WILL 'N
AS -DESIGNED AND APPROVED ON THIS APPLICATION'
-APPROX,DATE OF INSTALLATION A-iiiattl e of ApplIcant
SANITARIAN +S COMMENTS:
-"THIS .00NSTITFx-S RMI N HEALTH OFFICER'S -SIGNATURE -APPEA11 AS APPROVED
PLAW-APPROVED_�---- DISAPPROVED DATE .LO�
_,SANITARIAN
REMARKS: C)0,Z"e-
I CERTIFY THAT TH;4 SYST12KWAS INSTALLED IN THE MANNER APPROVED BY THE REALT-L
DEPARTK0T. 4411- AL -1
I]Vo37f LLEA-1 S NAME DATE
SKETCH PLAN ''I ON OR#
BELOW
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BETWEEN LINES lif q' ` �
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