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tj'PE·bF.CONsTRUCTIQN •
1 New Installation
IJ Dwelling
IJ Other Describe
-.. ~'
INDIVIDUAL SEWAGE
DISPOSAL SYSTEM
(ISDS)
PERMIT APPLICATION
I Maili~A~ra~------------------------------•
Mailing Address:------------------------------
Engineer: _L.;;:;...:...;;..;.____;_......;;;.&...;. __ =....=..:.;.;.;::~:......;.-----Phone: (....._ __ -....... --.---. ....... ,,._ __
Mailing Address: ____________________________ _
Job Address:_-..r-...-.. ........ ~~....;.,---"-=--..,_;;.-1---"""-"-----....,.~ ............ ~----~
Assessor's Parcel Number: Z'4)·0fl{ ·iJiJ.lfi Sub. ________ lot Block
Building or Service Type: llff{w~ ~ #Bedrooms: HI A-Garbage Grinder !:!/Jr
Distance to Nearest Community Sewer System: ___..tN."""""'~....;.;.""""-.,J ______________ _
Was an effort made to connect to the Community Sewer System: VH
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Type of ISDS j J!l Septic Tank f 0 Aeration Plant I 0 Vault I 0 Vault Privy I 0 Composting Toilet
D Recyding, Potable Use 0 Recyding 0 Pit Privy J 0 Incineration Toilet
D Chemical Toilet D Other _______________ _
I Ground Conditions Depth to 111 Ground water table Percent Ground Slope ------
Final Disposal by D Absorption trench, Bed or Pit .Bl Underground Dispersal 0 Above Ground Dispersal
D Sa~dFllt;;--·---------·--D Evapotranspiration -----------·· 0 Wastewater Pond
0 Other ----------------~-~~-----
Water Source & Type ~ Well 0 Spring 0 Stream or Creek d Cistern
0 Community Water System Name-----------------
Effluent Will Wluent be discharged directly into waters cf the Stat~? 0 Yes ~·No
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• '?;l, ,.,\ . ._ • '.-...· -.~ . 1 • I , • • :) . &"":; , ,...._,~1~ I·~;• _..,
Applicant acknow e dges that the completeness of the application is conditional upon such urther
mandatory and additional test and reports as may be required by the local health department to be
made and furnished by the applicant or by the local health department for purposed of the evaluation
of the application; and the issuance of the permit is subject to such terms and conditions as deemed
necessary to i nsure compliance with rules and regulations made, information and reports submitted
herewith and required to be submitted by the applicant are or will be represented to be true and
correct to the best of my knowledge and belief and are designed to be relied on by the local
department of health i n evaluating the same for purposes of issuing the permit applied for herein. I
further understand that any falsification or misrepresentation may result in the denial of the
application or revocation of any permit granted based upon said application and legal action for perjury
as provided by law.
I hereby acknowledge that I have read and understand the Notice and Certification above as well as
have provided th r, quired information which is correct and accurate to the best of my knowledge.
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Property owner Print and Sign Date
;';-. 1 ... ·-' '• ' . '
I
Spedal Conditions:
Perk Fee: tv\,f1.... Total Fees: ti:; .0\)
Fees Paid:
11..-3' ·00
Issue Date: Balance Due: (/:>
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BLDG DIV: --f,,t.~~~~===.;;;....'----__,.../.~-------------
APPROVAL ~