HomeMy WebLinkAbout28 Eagle Crest Dr - 210518102003 - 0798I - OWTS-9-12-8034INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT
Eagle County Department of Environmental Health PERMIT N2 0798
P.O. Box 850 - 550 Broadway
Eagle, Colorado 81631
Telephone: 328-7311 or 949-5257 or 927-3823
YELLOW COPY OF PERMIT MUST PLEASE CALL FOR FINAL INSPECTION BEFORE
BE POSTED AT INSTALLATION SITE COVERING ANY PORTION OF INSTALLED SYSTEM
Owner: Ted and Anne Close Telephone: 771-0216
Address: 4875 So. Fairfax, Littleton, CO
System Location: Lot 38, B1 k 6, Lake Creek Meadows
Licensed Installer: License Number:
Conditional installation approval is hereby granted for the following:
Minimum requirements:Gallon Septic Tank or Aerated Treatment unit
Absorption area of dispersal area computed as follows: cti lti�gh ,r•ti�� /F !, 5� l`.
Percolation rate: �� Inch in Minutes 2,2 ,�,�s�� {' r, C
(� �<
Absorption area per bedroom Sq. Ft. 7
Number of Bedrooms X Sq. Ft. minimum requirement per droom
equals Total Sq. Ft. minimum requirement
Special Requirements: 'EX` l<
Date: f/ Environmental Health Officer: z
CONDITIONS:
1. All installations must comply with all requirements of the Eagle County Individual Sewage Disposal System
Regulations, adopted pursuant to authority granted in 25-10-104, C.R.S. 1973, as amended.
2. This permit is valid only for connection to structures which have fully complied with County zoning and building
requirements. Connection to or use with any dwelling or structure not approved by the zoning and building
departments shall automatically be a violation of a requirement of the permit and cause for both legal action and
revocation of the permit.
3. Section III, 3.21 requires any person who constructs, alters or installs an Individual Sewage Disposal System to
be licensed according to the regulations.
FINAL APPROVAL OF SYSTEM:
No system shall be deemed to be in compliance with the Eagle County Individual Sewage Disposal System
Regulations until the system is approved prior to covering any portion of the system.
INSTALLED ABSORPTION OR DISPERSAL AREA. k SQ. FT.
INSTALLED SEPTIC TANK: 00 GALLONS; DEGREES; C� FEET
DESIGN ENGINEER OF SYSTEM:
INSTALLER OF SYSTEM: �2 % ' �' �' �� y r PHONE: 2L 2
SEPTIC TANK CLEANOUT TO WITHIN 12"OF FINAL GRADE OR
AERATED ACCESS PORTS ABOVE GRADE: YES NO
PROPER MATERIALS AND ASSEMBLY: YES NO
COMPLIANCE WITH PERMIT REQUIREMENTS: YES NO
COMPLIANCE WITH COUNTY./ STATE REGULATION REQUIREMENTS: YES NO
COMMENTS: 14l�ie.n9��
,•��, --';,-fir" l r�
(Any item checked NO requires correction before final approval of system is made. Arrange a re -inspection when
work is completed.)
DATE at ENVIRONMENTAL HEALTH OFFICER:
DATE (Re -Inspection) ENVIRONMENTAL HEALTH OFFICER:
RETAIN WITH RECEIPT RECORDS PERMIT
Name of Applicant: Hasel horst Carpentry Name of Owner: Ted and Anne Close
Amount Paid: 150.00 Receipt Number: 3467 Date: 7/&7 Cashier: F • Hueni nk
Check #4218
White and Pink Copies - Environmental Health Department Yellow Copy - Applicant / Owner
APPT ICAT" FOR ": aL SF \(: DIS,'S:�L :S- Fcv•.,T_
E:1'IRONXENTAL EEALT111 OFFICE - EAGLE COUNT:
P.O. pox ;;50
r Eagle Colorado 51631 No.
PER -MIT APPLICATION F'EE: S150.(�o 328-7311 PFRCOL\TIO`1 TEST F $125.00
NAME OF OWNER:
ADDRESS: 349V5 So.
L iV -OLY LAA (
C,o1P PHONE:
-/7l 'C,a1(0
NAME OF APPLICANT (if
different From owner) : /7/A
Se ( j,, L, Y C,
a y n e-,A 4,nS/
ADDRESS: (?,cox rl
107 T cvCCv j C
PHONE:
9a�'3 ell5v-
DESIGN ENGINEER OF SYSTDI (if applicable) : Mc. &C2W rk.
ADDRESS: I -) nX __ oQ -1-% R "- - I !" I _ /-_ I r-9dn':E: - 47aC
�' ctk 461s -717`r�32
is"t VI iLuL "cINSTALLATION OF SYSTEM:
Licensed Installer (see attached list): YES NO
ADDRESS:
- PHONE
PEK1IT APPLICATION IS FOR: OP<� New Installation ( ) Alteration ( ) Repair
LOCATION OF PROPOSED INDIVIDUAL SET•?AG"' DISPOSAL SYSTE7-1:
Street/Rural Address: ` "
Lot Size:
Legal Description: L _-v -z
BUILDI`7G OR SERVICE TYPE (check applicable cate^-ory) •
(X) Residential - Single Family
( ) Residential - Duplex
( ) Residential - Tr_olex
NUMBER OF PERSONS: IQ G5 G
WASTE TYPES (check applicable cate^ories):
( ) Cor-mercial or Institutional
( ) Non -Domestic Wastes
( ) Garbage Disposal PCISe-
(>Q Automatic Washer
( ) Other
-TYPE
OF
INDTVIDUAI. SET -.AGE
DISPOSAL SYS=-1 PROPOSED:
Septic Tank
(
) Composting Toilet
(
)
Vault Privy
(
) Greywater
(
)
Pit Privy
(
) Aeration Plant
(
)
Other
( ) Residential - Quadolex
( ) Co---::ercial (state usage)
NTLMBER OF BED -ROOMS: Z>
b-4) Dwelling
( ) Transient Use
Dishwasher
( ) Spa Tub
( ) Incineration Toilet
( ) Chemical Toilet
( ) Recycling, Potable Use
( ) Recycling, Other Use
WILL EFFLUENT BE DISC:iA_RGED DIRECTL`i INTO ?.'AT_RS OF THE STATE: YES
IS SYSTEM DESIGNED FOR LESS 7JAAN 2,000 GALLONS PER DAY: YES ( ) NO
WASTEWATER FLOW REDUCTION PLAN: YES ( ) NO
(I S Ves , see a.t tachzd ccas.te cater S.Zcw .reduction methods) C11
NOTE: The EnvZ1Lo;une;LtaZ Heae vt OSS.Zce may reduce die-teou,i.red ab,so,,Lpti.cn atea upon
apptovae 03' an adequat . teas -tzxat.,.1, StCUJ ,,LedUC_tCo;L pia;?.
SOURCE AND TYPE OF [dATER SUPPLY: ( ) Well
( ) Spring ( ) Creek/Stream
Give depth of all wells within 200 feet of system:
If supplied by community water, give name of supplier: Zn /YP (' ,,, !r ram. c�,o wS
SIGNATURE- - - - - - --L91 ------------ - - - - - -DATE- -- - f - -----
INFORMATION BELOW TO BE FILLED OUT BY ENVIRON!V.FrAL HEALTH OFFICER:
GROUND CONDITIONS: Pencent G,tound S.Zope
Depth ,to Bedtoch (pen 8' Ptoo'ift Hole)
Depth to Gnoundxa tc`c Tab.ee
SOIL PERCOLATION TEST RESULTS:. M.cnutcs per .ucc;t in Ho,.e �l
,ktbut,tes pert .inch .to Ho.ee # 2
i"L_i.;tu.tus pe%L iiEck to Ho.Ze #3
FINAL DISPOSAL BY:
( ) Abso.tp.tZoA Tne;teli, Bed o,,L Piet ( ) Fvapo,ttauspita,tc:on
( ) Above GtLcu;id D.ispe.naZ ( ) Sa;td FLE'ter
( ) Unde,tg•tound Dispnsae ( J Was.t:Lca.tct Pond
Amuu;Lt PaZd: a-v ReceZ,ut Ntunbe.r
--------------------- `- r7
NOTE: Site Plan must be attached to application.
(Env. Health Department - Rev. 4-07-33)
EAGLE COUNTY BUILDING DIVISION INSPECTION REQUEST
P. O. Box 179
Phone:328-7311 RI III IIIIUI' DCDRAIT Alr%
DATE: : s / 7
JOB -- --.._ _....... ._
NAME:TIME Q
RECEIVED: PM .. !�/S^ o
R
CALLER:
BUILDING
COVER
PLUMBING
MECHANICAL
ELECTRICAL
❑ FOOTING
❑ INSULATION .,
❑ GROUND IRON
❑ VENTILATION
❑ TEMPORARY
❑ FOUNDATION
❑ DRYWALL
❑ ROUGH
❑ HEATING
❑ ROUGH
11 FRAMING
❑ VE4EER
❑ FINAL
❑ HOODS
❑ FINAL
❑ FINAL
❑ ROOF
❑ ......................
❑ ........................
❑ ......................
❑ PARTIAL
❑ PARTIAL
❑ PARTIAL
❑ PARTIAL
❑ PARTIAL
❑ OTHER:
LOCATION:
❑ PARTIAL
Ready for Inspection: ❑ MONDAY ❑ TUESDAY ❑ WEDNESDAY ❑ THURSDAY ❑ FRIDAY ❑ AM ❑ PM
COMMENTS:
/
' APPROVED
DISAPPROVED REINSPECT
Upon the Following Corrections:
y-
DATE:
TIME:
INSPECTOR
0798 Close Lot 38 Blk 6 Lake
JOB NAME _ Creek Meadows--�-181-02-003
/JOB LOCATION
BILL TO
DATE STARTED
DATE COMPLETED
JOB 'NO.�_
63 �� 1
JOB COST SUMMARY
V- TOTAL SELLING PRICE
TOTAL MATERIAL'
WWA
TOTAL LABOR
TOTAL JOB COST
GROSS PROFIT
LESS OVERHEAD COSTS
% OF SELLING- PRICE
NET PROFIT
Printed in USA
to`
CONSTRUCTION GUIDE LINES_
2' 3' 3 2 - ,
a.. Site Preparation -
b'-Fill Ftacersent
a) 2" LAYER OF STRAW OR COVER - - - - - _ - -:-Step-1: Place the fill material- an the'--upslope edges of the lowed _
WITH UNTREATED BUILDING PAPER - prod construction techniques are essential if the wound is to function* P
3 NATIVE N FILL1 properly. The following techniques should be considered-
T-- - headam Keep
I _ - _ it off the plowed area Minimize traffic oa
SEED TOP OF MOUND F�------�------ IN 6" TOPSOI'
12"OF Step 1: Rope - off the site to prevent damage to the area during other- Step 2: Move. the fill material into place using a small track type
WITH GRASS MIXTURE - //'✓� - - .tractor with a=blade. -Always keep a minimum of 6 in. -of mate-
4" PIPE 1/2 -2 1/z�. �� construction activity on the lot. Vehicular traffic over the
area should be prohibited to avoid sell compaction. ria} beneath the tracks of the tractor to minimize compaction
SAND 1 CLEAN STONE - of the natural _ soil. - The fill material should be worked in
Step 2: Stake out the mound perimeter and bed in the proper orients-
TILLthis manner until the height of the fill reaches the elevation -
OR PLOW 6" OF - �, - - tion. Reference stakes set some distance from the mound pert-- _ of the top of the absorption bed.. - - - - - - -
NATURAL GROUND - meter are also required iR case the .corner stakes are dis-
turbed. Step 3 With the blade of the tractor; form the absorption bed. Hand
t N,
-
]ere? the bottom of thebed, checking it for the proper eleva-
Step 3; Cut and remove any excessive vegetation. Trees should be cut t1on.. Shape the sides to the desired slope.
at ground surface and the stumps left. in place.
EXISTING GROUND ASSUMED HIGH WATER TABLE - -
Step 6: Measure the average ground elevation along the upslope edge of t. _Distribution Network Placement -
�_ the bed to determine the bottom elevation of the bed.
- Step 1:- Carefully place the coarse aggregate in the bed. 'Do not create."
TYPICAL M L) N D S E C T I 0 N Step 5: Install the delivery pipe from the" dosing chamber -to the ruts ' in the bottom of the -bed. Level the r
wound. =Lay the pipe below the frost line or slope it uniformly aggregate egaU to a _
SCALE 1�= 5' `back to the dosing chamber so it may drain after dosing. Back minimum depth of 6 in. (15 cm).
fill and compact the soil around the pipe. Step 2: Assemble the distribution network on the aggregate. The wani-
Step 6` Plow the area within the mound perimeter. Use a two bottom or fold should be placed .so it will drain between doses, either
60 \ out the laterals or back Into the pump chamber. The laterals
larger moldboard plow, plowing T to 8 in. (19 to 20 cm) deep should l told level.
parallel to the contour. Single bottom plows should not be as-
37. s' ed. as the trace wheel runs in every furrow, compacting the Ste 3' Place additional - p aggregate to a depth of at least 2 in. (S-cm)
soil. Each furrow should be thrownupslope. A chisel plow may . over the crown of the pipe.
be used in place of a moldboard plow.: Roughening the surface
with backhoe teeth may be satisfactory, especially in wooded Step 4: Place a suitable backfill barrier over the aggregate.=-
sites with stumps. Rototilling is not recommended because of
EDGE OF CLEAN _ - - - the damage it does to the soil structure. However._rototilling,-
ro may be used in granular soils, such as sands.
STONE b d. Covering
Plowing should not be done when the soil is too wet. Smearing -
- and compaction of the soil wfTT occur. if a sample of the solitaken en the Step I:- Place a finer textured soil material such as clay or silt Tears -'
,\ (w Palms, f therow tsoilhe lis ow depth
wets tIf itwire wcrumblesen ,�plowing-may -
-over the top of the bed to a minimum depth of 6 in_ 115 cm).-
\ ( o proceed. - Step 2: Place 6 in. (15 cm) -of good quality topsoil over the entire
o mound surface.
Step 3. `Plant grass over the entire mound using grasses adapted to the _
I w area- Shrubs can be planted around the "se and up the side
-
0 slopes. Shrubs should be somewhat moisture tolerant since the
" downsiope perimeter way become moist during early spring and
4" PERFORATED PVC O'%FT PLUG OR CAP ENDS
_ - - late fall.. Plantings -on too of themoundshould be drought
tolerant, as the upper portion of the mound can became dry
I ro during the summer..
70�-\---- -- — �0
\ 4" SOLID PVC O"/FT COMMONLY USED FILL -MATERIALS AND THEIR.
DESIGN INFILTRATION -RATES
DIVERSON
VALVE
-tDesi -
4" SOLID PVC OR CAST IRON PIPE 1/4"/FT - - - _ _ - - Infiltration -- _
Fill Material Characteri sticsa " Rate
9Pd/ft2
80 \ \
Medium Sand <30$35% 0.25-2.0 mm -1.2 -
\ - TO SEPTIC ANK - - - _
\ \ \ <5-10% 0.002-0.05 mm
\ - o Sandy Loam 5-15% Clay Content 0.6
\ ( LATERAL DETAIL Sand/Sandy Loam 88-93% Sand 1.2 _
Mixture 7-12% Finer Grained
\ \ SCALE I 5' Material 7.
o \ Bottom Ash
12
\
\ \ �O DESIGN CRITERIA _
Slope 8-1
\ \ 2. Percolation rate in subsoil 5 m .i._= 2.2 .d. s . ft.
\ ` 3. Ground water depth = 1.5 feet (assumed), g P l q
\ 4.- Flow three bedrooms x 150 g•p.d. = 450 g.p.d.
\ 5. Using mediLIM sand/loam: -Infiltration rate 1.2 g.p.d./sq. ft.
\ \ 6 Absorption area required:- 450 . .d. _
1 \ _ � g p /Y 2 g•P•d•/sq-- ft. 375 sq.ft. ,
/ \ \ 7. Basal area required: 450 g.p.d./2.2_ d./s ft 204 s ft.
g'p' q• q•
\ 8. Basal area provided: {44-14j(68}= 2040 sq. ft.
NOTES
\• z
0 1. -Natural plants will be undisturbed as much as possible.
2. All disturbed areas will be r etated with natural
\ / I o' of 4�_ L, .�-_ - , , eveg grasses.
3. All mterials, installation practices, setback requirements
SLOPE
\ , etc. shall conform to Eagle County's Individual Sewage Disposal_
Systern Regulations.
\ SE'R,TIC TANK The 4.-.
\ \-i engineer and Eagle County shall be notified when construction
commences and kept abreast of the construction process so that
j \ sufficient inspection can be
4 Pvc _ . Performed to'assure conformance
\ SLOPE 1/4"/FT. — to theseplans. ,
\ APPROXIMATE EDGE OF MOUND .
� SEE DETAIL 5._ Fill material -
,shall have an infiltration rate of 1.2 g.p.d./sq. ft.
i�. medium sand -or sand/sandy loam mixture.
\ PROVIDE CLEANOUT
O \ \ 5 -
���,LA
VERSION \
` ALVE 7
PROVIDE POSITIVE DRAINAGE \
� AROUND MOUND .
i
.. \ SCALE i"= 20'
MS-
MacKown Surveying & Engineering, Inc.
P. 0. Box 323
Q 409 Brooks Lane • Eagle. Colo. 81631 (303}328-7203
SEPTIC. SYSTEM
CLOSE RESIDENCE
LOT 38, -BLOCK 6,
LAKE CREEK MEADOWS- SUBDIVISION
DRN. LIM
DES. -
REV.
CHK. JM
REV..
SHEET t OF I -
DATE 2 9- J U LY
87
REV.
JOB NO. 8 7/0 27
Work Classification: AlterationPermit
PO BOX 788
EDWARDS CO 81632-
PO BOX 788
EDWARDS CO 81632-
Address Owner Information
Permit Status: Active
Project Address
210518102003
Permit Type: OWTS Permit
Permit NO. OWTS-9-12-8034
Expires: 1/10/2013 Issue Date: 9/12/2012
Parcel No.
000028 EAGLE CREST RD Suite: B EDWARDS AREA, CO
Private Wastewater
System
Environmental Health
Department
P.O. Box 179
500 Broadway
Eagle, CO 81631-0179
Phone: (970)328-8755
Fax: (970)328-8788
Phone: (970)390-2401
Cell:
Inspection
For Inspections call: (970) 328-8755
Inspections:
IVR
PhoneEngineer(s)
Contractor(s)Phone Primary ContractorLicense Number
WY Construction (970)328-6641 Yes
RICHARD PATRIACCA
Permitted Construction / Details:
This permit granted to sleeve the sewer pipe that will be under a new drive way.
If any cast iron pipe is found from the original installation it will need to be replaced with a minimum of
SDR 35 sewer pipe. Add blue board under the driveway for frost protection.
Call Eagle County Environmental Health for inspection before covering the system.
Issued by: Environmental Health Department, Eagle County, CO
September 12, 2012
Date
Customer Copy
Terri Vroman
CONDITIONS:
1. THIS PERMIT EXPIRES BY TIME LIMITATION AND BECOMES NULL AND VOID IF THE WORK AUTHORIZED BY THE PERMIT IS NOT
COMMENCED WITHIN 120 DAYS OF ISSUANCE, OR BEFORE THE EXPIRATION OF AN ASSOCIATED BUILDING PERMIT
2. ALL INSTALLATIONS MUST COMPLY WITH ALL REQUIREMENTS OF THE EAGLE COUNTY INDIVIDUAL SEWAGE DISPOSAL SYSTEM
REGULATIONS ADOPTED PURSUANT TO AUTHORITY GRANTED IN C.R.S. 25-10-101, et seq., AS AMENDED
3. THIS PERMIT IS VALID ONLY FOR CONNECTION TO STRUCTURES WHICH HAVE FULLY COMPLIED WITH COUNTY ZONING AND
BUILDING REQUIREMENTS. CONNECTION TO, OR USE WITH ANY DWELLING OR STRUCTURE NOT APPROVED BY THE ZONING AND
BUILDING DEPARTMENTS SHALL AUTOMATICALLY BE A VIOLATION OF A REQUIREMENT OF THE PERMIT, AND WILL RESULT IN
BOTH LEGAL ACTION AND REVOCATION OF THE PERMIT
4. CHAPTER IV, SECTION 4.03.29 REQUIRES ANY PERSON WHO CONSTRUCTS, ALTERS OR INSTALLS AN INDIVIDUAL SEWAGE DISPOSAL
SYSTEM TO BE LICENSED
Work Classification: AlterationPermit
PO BOX 788
EDWARDS CO 81632-
PO BOX 788
EDWARDS CO 81632-
Address Owner Information
Permit Status: Active
Project Address
210518102003
Permit Type: OWTS Permit
Permit NO. OWTS-9-12-8034
Expires: 1/10/2013 Issue Date: 9/12/2012
Parcel No.
000028 EAGLE CREST RD Suite: B EDWARDS AREA, CO
Private Wastewater
System
Environmental Health
Department
P.O. Box 179
500 Broadway
Eagle, CO 81631-0179
Phone: (970)328-8755
Fax: (970)328-8788
Phone: (970)390-2401
Cell:
Inspection
For Inspections call: (970) 328-8755
Inspections:
IVR
PhoneEngineer(s)
Contractor(s)Phone Primary ContractorLicense Number
WY Construction (970)328-6641 Yes
RICHARD PATRIACCA
Permitted Construction / Details:
This permit granted to sleeve the sewer pipe that will be under a new drive way.
If any cast iron pipe is found from the original installation it will need to be replaced with a minimum of
SDR 35 sewer pipe. Add blue board under the driveway for frost protection.
Call Eagle County Environmental Health for inspection before covering the system.
Office Copy
September 12, 2012
Issued by: Environmental Health Department, Eagle County, CO Date
Terri Vroman
CONDITIONS:
1. THIS PERMIT EXPIRES BY TIME LIMITATION AND BECOMES NULL AND VOID IF THE WORK AUTHORIZED BY THE PERMIT IS NOT
COMMENCED WITHIN 120 DAYS OF ISSUANCE, OR BEFORE THE EXPIRATION OF AN ASSOCIATED BUILDING PERMIT
2. ALL INSTALLATIONS MUST COMPLY WITH ALL REQUIREMENTS OF THE EAGLE COUNTY INDIVIDUAL SEWAGE DISPOSAL SYSTEM
REGULATIONS ADOPTED PURSUANT TO AUTHORITY GRANTED IN C.R.S. 25-10-101, et seq., AS AMENDED
3. THIS PERMIT IS VALID ONLY FOR CONNECTION TO STRUCTURES WHICH HAVE FULLY COMPLIED WITH COUNTY ZONING AND
BUILDING REQUIREMENTS. CONNECTION TO, OR USE WITH ANY DWELLING OR STRUCTURE NOT APPROVED BY THE ZONING AND
BUILDING DEPARTMENTS SHALL AUTOMATICALLY BE A VIOLATION OF A REQUIREMENT OF THE PERMIT, AND WILL RESULT IN
BOTH LEGAL ACTION AND REVOCATION OF THE PERMIT
4. CHAPTER IV, SECTION 4.03.29 REQUIRES ANY PERSON WHO CONSTRUCTS, ALTERS OR INSTALLS AN INDIVIDUAL SEWAGE DISPOSAL
SYSTEM TO BE LICENSED
DEPARTMENT OF
ENVIRONMENTAL HEALTH
(970) 328-8755
FAX: (970) 328-8788
TOLL FREE: 800-225-6136
www.eaglecounty.us
EAGLE COUNTY
P.O. Box 179
500 Broadway
Eagle, CO 81631
www.eaglecounty.us
OWTS PERMIT # - b 3 q BUILDING PERMIT # _Z E 5 - 9- - /a -- �7& 70
INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED (SITE PLAN MUST BE INCLUDED)
FEE SCHEDULE
APPLICATION FEE $800.00 MAJOR REPAIR FEE $800.00 MINOR REPAIR FEE $400.00
This fee includes the OWTS Permit, Site Evaluation (Percolation Test, or Soil Profile Observation) and Final
Inspection. Additional fees may be charged if a re -inspection is necessary, or a pre -construction site visit or
consultation is needed. The re -inspection fee is $135.00
Make all remittance payable to: Eagle County Treasurer.
Property Owner: 1? 1 C,1 A r %-) � %/ /,� G G Phone: / q ;o `% 2 ; 5—G % Z
Mailing Address: / d m /vis email
/G3z-�
Registered Professional Engineer: Phone:
Applicant or Contact Person: W Phone: 197Q 5,7a _63'K3
Licensed Systems Contractor: License #
Company / DBA: Phone:
(( I
Mailing Address: email
Permit Application is for: New Installation A Alteration Repair
Location of Proposed Onsite Wastewater Treatment System:
Legal Description: O d � !K' /C AG 4 /; G / I� 5 %~ _r /y, IC 110 '0
Tax Parcel Number: /65- lelo-goo 3 Lot Size:
Assessor's Link: www.eaziecount-y.us/patie/
Physical Address:
Building Type:
Residential / Single Family
Residential / Multi Family
Number of Bedrooms:
Number of Bedrooms:
Commercial / Industrial* Type of Use:
*These systems require design my a Registered Professional Engineer
Type of Water Supply: Private Well Spring
If Public Name of Supplier: !r ,
Applicant Signature:
************************* ***********************
Surface J Public
********************************
Office Use Only a ����
Amount Paid: ��� Receipt #: Check #: Date: c1' C
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