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Lot # Subdivision Approval Date: ,V� �
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', Property Address: � Zone of Contribution: In Out '� _
Installer: ...�1.Y1 �jy�QC�,��Cl�
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� Owner: ( � �� Engineer: ������tiy1 '
N A Yes No
Number of copies received, 4 copies resid./6 copies comm.
i Soil ,logs and percolation test not older than 2 years
� 4 feet of naturally occurring pervious material, above water table
� Foundation 2 feet above high point in fronting road
� Water Availability letter from Water Department
Benchmark indicated and shown
Sewer does not exit center of house
Septic tank a minimum of 10 feet from house and deck
{ Leaching a minimum of 20 feet from house and 10 feet from deck
Leaching a minimum of 100 feet from wetlands
Leaching a minimum of 150 feet from wells ,
i Meets all other setback reauirements
° Adjustment used for maximum high groundwater
System 4 feet above adjusted water table or bottom of test pit .
LPaching not in top or subsoil or 10 foot removal
P�oposed contours are suitable
Meets slope requirement
Meets breakout requirement - calculations shown
j Specified tee sizes are proper
Sewage flow under 20,000 gpd for parcel
No garbage disposal
System adequately sized for its intended use
�gineer to certify:
� Clav removal
I Septic installation .
� 25 foot removal
Commercial svstem
Enqineer and Land Surveyor stamp & signature
H20 loadina when svstem is subject to vehicular traffic
Aoplication and fee signed by licensed installer
Foundation footing 2 feet above adjusted water table
Subdivided prior to July 31, 1986 - Nitrate Loading
Subdivided prior to April 7, 1989 - Phosphorous Zone 300'
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' Reviewed by: � C� �tJk7�-�
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