HomeMy WebLinkAboutPermit Septic Tank 1987-7-2
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....1 MUST BE IN BLACK INK .J
Permit No. }?O?'i-87TwnshP. i~ Range 03 Sectio~ Iq
Standard System 0 Alte;;;';;tive System ~ (Specify Typo) .~... fJg.W'
Job Location (Street Address) J Xo 'D-A:L.O ""<Uv ~~Je,,! fi.!O
Subdivision / Partition # Parcel Lot
form c55-11
Tax Lot I~
VICINITY MAP
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DETAIL SYSTEM PYl%.RJ,AN AS CONSTRUCTED
Scale ; "= ~'
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prauis(~ Orl-~ :31{1l 7f;1I:s/~ ,/" &Y&-y/ ?-;J-f7
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Installer -'8/Y.i..oada G....sf :ex
(Tille CIS shown on DEQ license}
. .phone ::J lit, <' c;.,~
lIrense No ';! ~ z..f'9
Bonding CompajIY C!! r:5
~ ~ Dato 7-:rj?
(Signature 01 L1censeel ,
If Installed By Owner-
USE BLACK INK ONLY '" W
FOR INSTALLER'S USE: Trench Dept~ 11 ~<< Gravel Depth Below Tiip u
Tank Capacity J~ . Manufacturo,. F'Vf"'''''"' t:2,/4N D
Measured Distance from Well to Tank 84 From Drainfield /00 Total Length of Lines /ZS
COMPLETE THE FOLLOWING IF A PUMP WAS USED ON THIS INSTALLATION:
I (installer's name) certify that a (Mfgl
and Mercury Float Switch IMfg. and No.1
(Model No.! Pump
have been installed with this sewage installation.
Signaturo
f'Jato
lSignatureof Ownerl
,Dato
FOR SANITARIAN'S USE ONLY: )'9..;;ystem Approved
COMMENTS: Sa> f)1tR. 3</0- J/-, 7'''':J
o System Disapproved
o Needs Correction
Applicant's Name & Address
,JatJut Lt':l':l.-ctI'
/ 20 Vead~AJ ..,~,...,.."
E~7 ~ ;t!J"t .
Z/J
System Capacity 4h7J
. ~IT) Corrected
~al./day Signature~~
Data
,Dato ~.k7
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INSTALLATION RECORO & CERTIFICATE OF SATISFACTORY COMPLETION When signed by the County Sanitarian. this certificate is
evidence as per GAS 454.665 of satisfactory completion of a subsurface sewage disposal system at the above location.
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