HomeMy WebLinkAboutSEP1972-0005379
caroune ETC_. HEALTH . DISTRICT 5 3 3
�inges Pee.Paid -� .......
SEWAGE DISPOSAL PERMIT APPLVATI b
Submit in Duplicate
6 Po &7C 131, Q�
'*dm* N/-, ADDRESS —v - _vim- Q
I .._DESCRIPTION i �"1 e � PHONE,
DIRECTIONS -FOR LOCATING
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APPLICATION IS HEREBY FADE TO: INSTALL NEW SYSTEK��21':FASR EXLn= SYSTEM,,;.
i��:��e JFSNA E O F BUILDING N0. OF BEDROOMS BASEMENT SITE srzE ME OF INSTA, RA A DETA P T P N GIV G T O LOWING INF)RHAT C
1* -property- lines 7* Driveways, patios, aarport4 etc. �
2. I.ocatton of building 8. Streams or bodies of water nearby
ion of septic tank 9. Location of percolation test holes
4+ t:Lon of drainfie,ld ti . 10.. Septic .tank size- 7
pe of °1anc 11 ®:Length of proposed drainfield
""a r lines .& well(if applicable) 126 Depth to water if encountered.
PERCOLATION TEST RESULTS
epth Time require to Percolation rate Type of soil
of hole seep last 6 in. tdivide time by 6)
Pere. No
,
Pere.. No. 2
Pete. No. 36
DB.EMIELD LENGTH a WIDTH ` DEPTH a! L &` N0. OF LINES.
TW
IS`$EREB3[ AGREED THAT THE PROPOSED INSTALLATION WILL BE MADE IN THE MANNER
n
L'14--I NED AND APPROVED ON THIS APPLICATION.
.. a Si ynature of-Applicant
ant -
.APPROY...D= OF INSTALLATION 5 � �p � °. \ � �-� 1�, .�.
-S TARIAN 9-1 C 0 *�Y S
��� `� �"�.�UY �. � �{ ,tea Y�.•, .a �3�. o:��`'�' '�
--ITM;CANSTTTU S ERM WHEN HEALTH OFFICER'S SIGNATURE APPEARS AS APPROVED S
PLAN _APPROVED DISAPPROVED DATE 6 �:.' - 411�
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REMARKS: �� ��� , v °� :a��\°�� d -` �j ^�-•,� '�;� -�
10136175 �, I\\�N
I CERTIFY THAT THIS SYSTEfii WAS INSTALL %& s>�ED" BY TOTE HraZTb
DEP.ARTHOT . ;
INSTALLER'S NAME D.&TE
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