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INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
OWNER TAM <, // ray .117
ADDRESS ago _ CF1 > Leo . P/69, PHONE 97 - 549— ZS IP6
CONTRACTOR /i/GerfrPV L you 4.2,
ADDRESS oa ds3 A PV N, eip-c . (o Fi6so PHONE 970 -62r-P7/3
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 of Town 5/1.r Size of Lot to 46eL
Legal Description or Address •Ec /Gvi' / "741 ■ &Ne DSa b
WASTES TYPE: (DWELLING ( ) TRANSIENT USE
( ) COMMERCIAL OR INDUSTRIAL ( ) NON - DOMESTIC WASTES
( ) OTHER - DESCRIBE
BUILDING OR SERVICE TYPE: /S6 o - Cif 2- (tPes /DeNes)
Number of Bedrooms 3 Number of Persons /
(4-) Garbage Grinder (,N Automatic Washer (4-) Dishwasher
SQURCE AND TYPE OF WATER SUPPLY: Ai WELL ( ) SPRING ( ) STREAM OR CREEK
If supplied by Community Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM: 75 .v it-4v ta
Was an effort made to connect to the Community System? A/U
A site elan is required to be submitted that indicates the following MINIMUM distances:
Leach Field to Well: 100 feet
Septic Tank to Well: 50 feet 6' t:
Leach Field to Irrigation Ditches, Stream or Water Course: 50 feet a. K
Septic System to Property Lines: 10 feet a •
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT
A SITE PLAN.
GROUND CONDITIONS:
Depth to first Ground Water Table /i/0 // n
Percent Ground Slope FlOJT 7v / ° c % a 70- -44
2