HomeMy WebLinkAboutSEP2020-00014r
903 E. Caroli -e Qt.3
l nT.ivMPIC HEALTH DISTRICT
Pait Aigeles 3 C2�1C�
SMIAGE DISPOSAL PERMIT APPLICATION
Submit in Duplicate
Court House
nr� 8 0 '56i& -ra,tf�,
Permit No,��
Builder
Date
PHONE
DIRECTIONS FOR LOCATING SITE
APPLICATION IS HIMEBY'MADE TO: INSTALL NEk-?._S.YSTEVL._.-�K REPAIR EXISTING SYSTEM
[YPE OF BUILDING
N0. OF BROOMS
..
BASEFiENT SI SIZJ
_. NAME OF INSTALLER
DRAINFIELD LENGTH_ i,rIDTH,EPTHIy-&.'#LINES r, SEPTIC TANK SIZE ® cam
"Tr it&xli'N%;cl6—1
PERMIT UNLESS PRIOR APPROVAL OBTAINED FROM THE�HEALTH` DEPARTMENT. � yja•rtLiL�l� i111A7
DATE OF INSTALLATION SIGN'ITURE OF APPLICANTS
APPROVED ��� DATE INSPECTED BY DATE
SANITARIAN IS C011AE VTS :
�))G
I CERTIFY THAT THIS SYSTEM ! AS IPiST'>LLED IN TITS MANNER APPROVED BY THE T`l
HEALTH DEAPRTMENT IDATE (j
PIST.ALLERS NAitiIE
;�. ON-SITE SE WAGE . ISPOSAL SURVEY OF
,1 -
a
Street Or
iv cion
Block Lot Lanftrk Lot', Size,
I. Lo'oation", Lot Size
ii. system Owner
Address.rj...
Telephone Number
; . permit uy (Previous Owner)
flai:e' Issued
.
IIT, I6sta'�l"er __
Average Number of People Served
9
f
N Date instal led 4 �?'
L,
Number of_- Bedrooms
Time Int -Service (years ).
Clothes Wisher
YES_'
NO' .
1 Septic jaink Pumped'
S _
OFTEN
:Dishwasher ,
Y-�----
�--=NO-,_ �..
# of Months/YearsResidence Occupied?-' '
Garbage Disposal
VE -;No
w '
IV Type of.tover over dra nfield. (i.e: grass,
landscaping, etc.
P .
, ;Er
Repairs. (When, what, who} Ouse of Failure
1f I . contents' (O�ter for . Sketchy
UVNpr
1)
1
3 VI I . Acts off..Taken
4
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