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10512772
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Last modified
6/29/2021 9:29:02 AM
Creation date
6/25/2021 2:20:33 PM
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Permits
Permit Address
11042 DOGWOOD LN SE
Permit City
LYONS
Permit Number
555-20-008467-AUTH
Parcel Number
093E18AB01100
Permit Type
Authorization
Permit Doc Type
Permit Document
Status
Ready to Film
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011)—o0By, (�1 — AVTI-� <br /> Marron EXISTING SEPTIC SYSTEM DESC RECL, W E <br /> NOV 20 2020 <br /> Please answer the following questions as completely as possible, and to the •41 •ON <br /> 1. Your existing septic system consists of(check all that apply): <br /> El Septic Tank MI Disposal Trenches 0 Capping Fill 0 Sandfilter <br /> ❑ Seepage Bed 0 Cesspool or Pit 0 Unknown <br /> ❑ Other (Describe) <br /> 2. When was your septic system installed? I q,F'Z Nd N 6 <br /> (Date) (PemiitNumber) <br /> 3. Tank material: 0 Concrete IT Steel 0 Plastic or Fiberglass 0 Unknown <br /> 4. Septic tank volume (in gallons) 5© ) <br /> wz <br /> 5. When was the septic tank, last pumped? I f[gfz ra Attach receipt if available. <br /> 6. Number of disposal trenches 2_ <br /> 7. Total length of disposal trenches (in feet) jt7 <br /> 8. Do you propose to use the existing septic system? Yes At No❑ D(S P©cAi Y"1�iwc frx�-S <br /> 9. Is your septic system currently in use? Yes 0 No 0 If no, date of last use <br /> 10. If the septic system currently serves a dwelling_ <br /> How many bedrooms are in the dwelling? How many people occupy the dwelling? <br /> 11_ How many bedrooms will be in the proposed dwelling? How many occupants? <br /> 12. If the septic system serves a business: <br /> How many total employees are there? NA <br /> Type of business <br /> 13. Is there a proposed change of use of your structure (home or business)? Yes ❑. No,g,l <br /> If yes,please explain <br /> 14. Provide a plot plan(sketch) on the reverse side of this form showing the best estimated or actual <br /> measurements that locate the existing septic tank and disposal trenches,property lines, easements, <br /> existing structures, driveways, and water supply.Indicate the direction of north. If you are proposing to <br /> replace the septic system, indicate the test hole location. <br /> By my signature,I certify that the above information and the plot plan on the reverse side of this form are <br /> accurate and true to the best of my knowledge. <br /> 11/7 di 0 L � <br /> te) Signa .e. • -term d Representative <br /> Office use only: Record of existing system: Yes❑ No 0 Attached 0 Datelssued <br /> Permit Number Certificate of Satisfactory Completion Issued YesO NOD Initials <br /> Other file information: <br />
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