A25 56Additional appliances to be used: Disposal, dishwasher, washing
machine
Recommended: Septic t8nk L ��� �i �-�•
Nitrification line: ' C� � ��2 �
Above recommendation based on information received and observed
soil condition. Sentic tank and nitrification line must be inspected and
approved bp a member of ihe Disf:ict Health Departmen! staff before
any portion of the installation is covered.
Date Approved: J`—..Z � 7Z
Signe�
� Sanitarian
By: � / i�
O. David Garvin, M.D., M.P.H.
District Iiealth Officer
Countersigned
(Over)
� NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on
adjacent property, etc. Write in measurements in order that installations may be located at later
date.
r SUGGESTED INSTALLATION (Date ) FINAL INSTAI�LATION (Date )
(Road or Street) (Road or Street)
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'�i �t�N�dY' (���9e�P�°�Y��.c"ea�r v �waes�J'ovcE LAN�a�M
Home Phon� � �
Business phort� 33 b 54'► 55� � DX R�RO C '1 5'i �
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3) Prcperly D'ae+�lpdon: Lat siz� Tawneh�:
Directiona tc the ProP�Y (��9 �• ��
4)
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Lot�:
Prop�sed t]es� �tts �on: ans�' �ch of the �oibwing qWest�n�x �... ��
�) prp� ,/� E�ng 'J'ype pf � D� B� E•1,0 i DE MOBiL� ElA _ 1Mdtf�.
b) Nurriher at fledcaom� � l►N.tmber of accupanfs or peopie bo be �rvecr �' ,
c) B� Yes _, No,�V�be ph�nb�9 in the �i? ._
�) � � Ye9 ,,,_, No X � � s •�. bti
o � •�- � ' "
W� Suppiy "lj�p� Ptivabe ✓(t�ear ,_ ar eods�ng �, Pub�c._, C�arr�r�nily..� S� _
At�e•any u� cn adjoin�g p�operly4 Yea _,,, Plo _ ttyee, p(�ase itu�raEe ap�n� icc�tcn an the s�e aen.
B� Does tha prop�rty �ro�in pt�evbwiy i�d jurl�lon�i �? Yes _ I�b _
PLEA9E NOTE THE FOLL0INING:
'➢ A PLAT OF li� PROP�TY OR Sf'� PLAN lft]9T 8E �l�T7� lAR'!�� THIS APPf.�C�►TIONL:
➢ Pti0P�7Y 1.lNE.9 AND COR�R9 �ftlST HE Cl.�ARLY YAR�. .
9. THE �OPC9� LOCAT1t9N OF ALL 9TRUC?LlRES Nt1ST BE 9TA1� OR AAC�. • .
9 THE St7E �AL187' BE RE�IDILY A�18LE FOR �1i�1 EYALUAT�N BY TM� HEALTH DH��R7�i@IT STAF�.
1• herehg m�aa �or� ie the Person Caurrty H�Nh O�artrr�ent ior a s�a evsi�n far the ott-sii�a sewaBe �a!
gY�m tar the above-d� property. 1 agr�ae #hat the con�ec�ts af this �pli�ion ace true ar►d reQr�nt the ma�num
� ta be piaced cn th� properiy. 1 und�and ii ihe s�a is ait�ed ar th� � u� changes, the pemui sfi�alt
� a, . (:�euca� ��fk.d°-� � . � �-' � o�
Oweer or L.Eaai Re�r�ra � � Date
p�p, � 10tt7J01
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�.r�►. ` 4 � �,� � � � �- V � �
�7�h�T3L�L�A�'D�Sl�'M� ��1��.�1 ���R.�'��
Tax Map # � t� Parcel # ��
Existing Sewage System Report For: V Mobile Home Replacement
Addition Type:
Requester: Halr-�,SC. ( t �.�G.C: � F i0r@1� �0. f�u.55�� ( Home Phone#
34S (-}�c�,i t, C(avfon le.oac� Business #�1" SS� '1_-
%OXbbt�. IvL o�_%s���� � (i ►rtll�lta �-'0.r��i/1�c T�tj
11
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Original Permit Located: � Water Supply: �rl ��- W t- <<
Septic System Designed For: �Residential Business Other
# Bedrooms� # Employees Other
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System Type: �UGttJ0�1C�.� Tank Size: Nitrification Line: � l0
Date Installed: � a-1a Certified Operator Required: ��
On-site wastewater disposal system shows no visual signs of malfunction on a���c7�
Pernussion is granted
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�s��� �rn t� w/ aa b� d�c�m l�.
�s�inti wc-[( , �S� To 5
� b t I-t!h o Vt'� Ori O r -� r"c.c�i � i�
Crr'-�i Ftca�c 0� ��c.ufla��cv
Environmental Health Specialist ` Date: ��,��