HomeMy WebLinkAboutSEP1970-00016► 1 r
,%)3 East Gamline QLMPIC HEALTH i;1GZq1GT Permit Noe
J"ort Angelps:-Paid -r
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yMAGE DIM?OSAL PMUT•
Submit n M-olicate,
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LEGAL�" �i — o.. .�1/t its :+: I 1
DIRECTIONS FOR LOCATING
APPLICAM ON is I HEMY MADE t _ M r uxta
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ON TETE REVERSE SIDE, DRAM' A DETAIM PLOT PLAN GIVING THE FOLLOWING INS FOWION;
1. Property lines 7. Driveways, patios* carport, etc.
2. Location of building 8. Streams or bodies of water nearby
3* Location of septic tank 9. Location of percolation test holes
4* Location of drainfield 10. Septic tank size ,-P allons
5. Slope of land 11. Length of proposed. drainfield
6, Water lines and well(if applicable) 12, Depth to water if encountered
PERCOLATION TEST RESULTS
Depth Time required to Percolation rateType of Soil
Of hole seep last 6 inches (divide time by 6)
Pere. No. L �....__.._.,
Pere. No, 2
Pere. No. 3
DRAINFIEL' D LENGTEi
__FdIM DEQ 141, NO. OF LINES
IT IS HEMy AGREE TEiAT THE PRDpOSED INSTALLATION: 'WILL BE D4ADE IN ME h AS
DESIGMM AND APPROM ON THIS APPLICATION.
Signature of Applicant
APPROX. DATE OF INSTALLAM ON, / Z
SANITARIANES CoI'S:
Now. I
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UN MIA
SKETCH
PLAN
ON'GRID BELOW
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SCALE-�1 FEES
UT EEN LINES
INDICATE NORTH
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ON-SITE SEWAGE DISPOSAL SURVEY OF
Street Or
n RlnnL I nt I anrlmarle
I. Location, Lot Size
II. System Owner
Address
'<Telephone Number
Permit (?) (Previous Owner)
Date Issued
u1�1F.1, E
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9
W,
BVI.
Type of cover over drainfield. (i.e.!' grass, landscaping, etc.)
A _
Repairs (whenwhat, who) Cause of Failure
i
Comments (Over for Sketch) 5,,$ 5D`9'!.
III. Installer `-
)(Average Number of
People Served
Date Installed 19)'I
Number of Bedrooms
3
Time In-Service(years) 9
VClothes Washer
\(Septic Tank .Pumped oto a
--
YES
NO
ES NO HOW
Y Dishwasher
OFTEN
YES
N0
X# of Months/Years Residence Occupied?
X Garbage Disposal
YES
NO
W,
BVI.
Type of cover over drainfield. (i.e.!' grass, landscaping, etc.)
A _
Repairs (whenwhat, who) Cause of Failure
i
Comments (Over for Sketch) 5,,$ 5D`9'!.