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Permll Issued To: Denni~ vietz, ke <br /> <br />Septic tcmk: Minimum liquid capacity with distdbulion box .... <br /> <br />Subsurface Disposal F~eld required '~ '~'~ Un, ft -_ -- .Width uT trench ~q, ft._ ~ <br /> <br />MARl' 17'=~-~ff~'fi0n 5peCi~i~(~zt-i~'s- ..... <br /> ___Property Address ~ gus, ~ A~sviiie <br /> <br /> Record Of Individual Sewage Disposal System <br />To Be Completed by Installer <br /> No _~'~:~/W~ Address _/ ~ ~.u'/~,.~- , ~ <br />Total number: Living units __Bedrooms__ Baths ..... Basement: Yes ~ No ~' <br /> <br />Water supply: Public syslem <br />Septic tank: Distance from well <br />rural IiqukJ capocity__~J'~' ~t ~~' <br /> Diameter <br />Tile disposal field: Distribution box? <br />Lenglh of each line ~ .. <br />Total length o¢ aU lines~ ~. <br />Width of trench <br />Iola[ square ¢ootage .............. <br />Dislance between lines <br /> <br /> Individual well ~ <br /> feet. Material <br />__.goh inside length <br /> ft. Liquid depth <br /> Yes ~ No I~J] Other <br /> __~'_S' ..... ~q"O <br /> ~t. <br /> <br /> ft. <br /> <br />type of filter maleriaJ; Grovel: ~ <br />Depth of filler material over tile <br /> <br />Sketch of instollc~tlan, ~" ~ ~ ,~. <br /> <br />Community system <br />__ No. of compartments ..... <br />.It, inside w~dth. .ft. <br /> <br /> Other <br />inches. Depth of tile below original ground surface <br /> <br />Well ._ft. <br /> <br />Lot line; Front [] Side[] Rear ~ ft <br />Foundation ft. <br /> Depth beneath tile, _inches. <br /> <br />Note: <br /> <br />indicate Northerly direction, <br />Ir~spectior~ will out be mode until completed form is returned to the Health. Dept. <br /> <br />System apparently will,,/Lz~ will not [] <br /> <br />(FOR HEALTH DEPT, USE) <br />~unctlon saHsFa~torily, and is ~heretore approved .[~'" D~sapproved [] <br />/\ <br /> <br />Copies; (I) Orig. HD Files <br /> <br /> MAI~!~.~TY H .Al,TH I)EpA R'rMEN'f '4~, -- <br />,.-- ~;,-; (/ <br /> <br /> <br />