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� �i✓' S'��� '��'t�- SEWAGE PLAN REVIEW CHECKLIST '
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Location: A.M.__��� Lot__;3.� Zone of Contribution: In Out� Acreage
� , Commercial: Residential:� ;
Street: ___.� ,
Village: Floor Plan: #Bedrooms:
Owner: �Z/�fA'Gf/%�t� Installer: /iL
Address: Phone: (��
Phone: � ���,,,�
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Builder: Engineer. # y `�'�`�/
Address: Phone: - (,' -
Phone: _ ����� , ,��i� s � �' �--f
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N/A N �"'
l.R uired#of co ies received
2.Date of soils exam and olation test not older than 2 ears �� ;
3.4-5 ft of natural occurrin ervious material,above water table
4.Foundation 2 ft above hi int of road H.P.: Fnd: Var.: �--
5. Wat�line 1 Q ft from s tic com nents Var.:
6.Benchmark indicated and shown-NGVD if near wetlands ��
7. S tic tank minimum 10 ft from foundation,deck Vaz.: ;/
8.Leachin minimum 20 ft full, 15 ft crawl, 10 ft slab Var.:
9.Leachin minimum 100 ft from wetlands Vaz.: � �./
10. Leachin minimum 150 ft from drinkin wel U25 ft irri tion well Var.: `�
12. Tank/leachin minimum 10 ft from r line Var.: �_
12. S stem meets all other setback irements Var.: .
13. Uses ad' stmeirt for maximum hi oundwater Var.:
14.Leachin set 4-5 �above ad'.water or test ho
15.S stem not in t or subsoil A,B horizons or 5'remov�l
I6.Pr ed coirtours are suitable
17. S stem mcets slo irements-min. 1/8", '/4" eferred ��
18. S stem meets breakout r irements PVC liner: alL•
19. S ified tee sizes are r , baffle on outlet tee
2Q. Sewa e is under 10,000 for arcel
21.No e dis osal
_ 22. S stem ad uatel sized for its intended use `�
23.Minimum 6"stone or com cted below tank and dbox �� '
24.Manhole covers within 6"of e, um chamber cover to e
� 25. Ins ion on lastic chambe,rs/leach field ��
26. Electrical e,rmit for wn chamber/S me,tex far du lexes �-
27.Pum stem-2" line,w� hole,check valvey tee in dbo� size �,/
28. S tic tank/ u chambe,r to be wa roofed ��
29. Yerrt ovided if leachin below 3 feet, under drivewa /
30. Buo anc ca�ulatians for tank/ um chamber '
3 I. En 'ne�r to ins ect and cert' soils: wall: commercial:
32.En 'ne,er/Re ' ered Sanitarian and Land Surv or stam s/si ture
33. H-201oadin is sub'ect to vehicutar traffic, dwater
34. Title V A licatian and ermit fce, install�si ture '
35.Foundation footin min.2 fcet above ad' ed ound water for new house
36. Dced Restriction uired max. #be�roams: �max. flow:
3�. Check area lots for oundwater/Label oundwater in Assessor's Ma
Plan revieweri by: _ �� ��