HomeMy WebLinkAbout03337~-r··:·~----:·.-y ····~,--··········
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1 ~ A11eaaor's Parcal No. -----~-~--
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CHARGES
Percolation Test $100.00
(inclu.des final Inspection) 'a ii
( ·r Permit Processing Fee $50.00
i ~ Check
11. Cash
; J Money Order
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Whle • APPl.ICANT
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YeDow ·DEPARTMENT
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1}::FJ331
\. INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION ~-&(Jo
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ADDRESS = T $ «e ftb PHONE 17D srt -)"\2 y
CONTRACTOR dN r,J. ~ Co ,.,,6-t: .f:.c. •
ADDRESS Sane.--PHONE __ ~)7 ___ 7_h_6_1=o'-'y_
PERMIT REQUEST FOR ( ) NEW INSTALLATION ( ) ALTERATION (~REPAIR
Attach separate sheets or report showing entire area with respect to surrounding areas, topography of area, habitable
building, location of potable water wells, soil percolation test holes, soil profiles in test holes (See page 4).
LOCATION OF PROPOSED FACILITY:
Near what City ofTown. ___ ~5~v_· ~(+ ___________ ~S=iz=e ..... o..._f=L~ot~7..___¥'"""u:.-'-~-'""'5 __
Legal Description or Address ___ 7~t .... 3 _ ___,/Z.=....4:--"'-.S_<_.c: ... o'-----'-~-'-O~-~'>"'""·_.(_,t...____,~,...o...._ _____ _
WASTES TYPE: ~WELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON-DOMESTIC WASTES
( )OTHER-DESCRIBE_-=--------------
BUILDING OR SERVICE TYPE: __ ... $"'i11-/ .... P.....r...~~-=::..::....-".:rr------------
Number ofBedrooms _~>--------~-----Number of Persons--"-----
( ) Garbage Grinder ( ) Automatic Washer
SOURCE AND TYPE OF WATER SUPPLY: <f><'_ WELL
( ) Dishwasher
( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier: _______________ _
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: ___________ _
Was an effort made to connect to the Community System? ______________ _
A site plan is required to be submitted that Indicates the following MINIMUM distances:
Leach Field to Well: 100 feet
Sepdc Tank to Well: SO feet
Leach Field to Irrigadon Ditches, Stream or Water Course: SO feet
Sepdc System to Property Lines: 10 feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT
A SITE PLAN.
GROUND CONDITIONS:
Depth to first Ground Water Table ______________________ _
Percent Ground Slope. __________________________ _
2
TYPE Of INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(~ SEPTIC TANK ( ) AERATION PLANT ( ) VAULT
( ) VAULT PRIVY ( ) COMPOSTING TOILET ( ) RECYCLING, POT ABLE USE
( ) PITPRIVY ( ) INCINERATION TOILET ( ) RECYCLING, OTHER USE
( ) CHEMICAL TOILET ( ) OTHER -DESCRIBE
FINAL DISPOSAL BY:
(~ ABSORPTION TRENCH, BED OR PIT ( ) EV APOTRANSPIRATION
( ) UNDERGROUND DISPERSAL ( ) SAND FILTER
( ) ABOVE GROUND DISPERSAL ( ) WASTEWATER POND
( ) OTHER -DESCRIBE
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE? ______ _
PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, if the Engineer does the
Percolation Test)
Minutes. _____ per inch in hole No. 1 Minutes ______ per inch in hole NO. 3
Minutes per inch in hole No. 2 Minutes er inch in hole NO. _
Name, address and telephone ofRPE who made soil absorption tests: ______________ _
Name, address and telephone ofRPE responsible for design of the system:. _____________ _
Applicant acknowledges that the completeness of the application is conditional upon such further mandatory and
additional tests 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 pennit is
subject to such terms and conditions as deemed necessary to insure 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 in evaluating the same for purposes of issuing the pennit applied for herein. I further understand that any
falsification or misrepresentation may result in the denial of the application or revocation of any pennit granted based
upon said application and in legal action for perjury as provided by Jaw.
Signed,,eg/?-Date,_.....:Y:.......-_t1_r-_~_c>_c=> ____ _
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPERTY I!
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Designate North Arrow
Your Neighbor's
Name & Address
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Your Plot -Shape to Fit
(No Scale)
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Locate well, all streams, irrigation ditchs, and any water courses. Draw in your house,
septic tank & system, detached garages, and driveway.
If a change of location is necessary, you must submit a corrected drawing, before a
Certificate of Occupation will be issued.
County Road (Note the Road Number and Name)
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Your Neighbor's
Name & Address