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Section III: AS BUILT: USE THIS FORM OR STATEMENT BELOW ON THE SUBMITTAL: Provide the as- <br /> built plan of the constructed system. Indicate the direction north, scale, and show all wells within <br /> 200 ft of the system; provide setbacks to all applicable items requiring setback. <br /> N <br /> fakArQ <br /> r .: <br /> • .e. ,�.; °yam-X,_ .«' , , <br /> (05 <br /> tv <br /> tn1�_ �_ <br /> r� `) Not..s 11' <br /> ll" <br /> _ew <br /> �a�Ls <br /> =SOU ,gut X 2 S2'94' <br /> _... .. <br /> I 0 ADDRESS 9, U L /I/ <br /> SECTION IV: CONSTRUCTION WAS DONE BY: <br /> I CERTIFY THE INFORMATION PROVIDED IN THIS NOTICE IS ACCURATE,AND THAT THE.CONSTRUCTION OF THIS SYSTEM <br /> WAS IN ACCORDANCE'WITH THE PERMIT AND THE RULES REGULATING THE CONSTRUCTION OF ON-SITE:SEWAGE DISPOSAL <br /> SYSTEMS(OAR CHAP. 340, Div.71 AND 73)ONLY THE OWNER OR A D.E.Q.LICENSED INSTALLER PERFORMED THE <br /> SEPTIC SYSTEM INSTALLATION.INSTALLATION DONE BY: <br /> _ r <br /> PRINT INSTALLER'S NAME: <br /> IF OTHER THAN OWNER-INCLUDE`COMPANY NAME AND DEQ LICENSE <br /> INSTALLER'S"SIGNATURE: <br /> IF OTHER THAN OWNER-PROVIDE CERTIFICATION#AND EXPIRATION DATE <br /> DATE DAY-OF-INSPECTION CONTACT PHONE.NUMBER: <br /> • <br />