HomeMy WebLinkAboutMiscellaneous Plans 1987-7-2
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....1 MUST BE IN BLACl< INK j
Permit No. }?O?'i-87TwnshP. i~ Range 03 Sectio~ Iq
Standard System 0 Alte;;;';;tive System ~ (Specify Typ"l .~... fJg-W'
Job Location (Street Addressl J Xo ~O ""<Uv ~~Je,,! fi.!O
Subdivision / Partition # Parce' Lot
form e55-ll
Tax Lot I~
VICINITY MAP
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DETAIL SYSTEM PYl%.RJ,AN AS CONSTRUCTED
Scale ; "= ~.
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Installer -'8/Y.iAJada G....sf :ex
(Tille CIS shown on DEQ license}
. .phone ::J lit, <' c;.,~
lIrense No ';! ~ z.f'9
Bonding CompajIY C!! r:5
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(Signature 01 L1censeel ,
If Installed By Owner-
USE BLACK INK ONLY '" W
FOR INSTALLER'S USE: Treneh Depth 11 ~<< Gravel Depth Below Tilp u
Tank Capacity J~ _ Manufaetur"c, F'Vf"''''-' t:2,/4N D
Measured Distanee 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 namel certify that a (Mfgl
and Mercury Float Switch IMfg. and No.1
IModel No.! Pump
have been installed with this sewage installation.
Signatur"
f'Jat"
lSignatureof Ownerl
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FOR SANITARIAN'S USE ONLY: )'9..;;ystem Approved
COMMENTS: Sa> f)1tR. 3</0- J/-, 7'''':J
o System Disapproved
o Needs Correetion
Applicant's Name & Address
. JatJut Lt';/':l.-ctI'
/ 20 Vead~A.I "'~M"'t
E~7 ~ ;t!J"t .
Z/J
System Capacity 4h7J
- ~IT) Corrected
~al./day Signature~~
Data
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INSTALLATION RECORD & 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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