HomeMy WebLinkAboutInspection Report 1995 Nov 21 _ �. �:. . ._ :
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� �'�� BOARD OE HE
�'� � A L T H � N OV � 5 �95
O� �,t` R�S'T F�2 SEPTIC SY5TEN1 II�FORMATION
� ',,-' (� t�r � �ta�Y oor�r�u) HEALTH DEPT.
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1. r�ocAT �,��ECTION: �a sc������r Rv�v yi���v�r�,o��r ��
2. Tow�v Ass�soR�s r� #_ �v�2 , tar # ���_ �
3. DATE HOUSE WAS BUI LT: /J 7�
4. WELL ON PROPERTY, INCLUDING IRRIGATION WELLS? YES NO �
(SHOW LOCATION ON SEPTIC INSPECTION FORM.)
5. OWNER'S NAME AND ADDRESS: �VofP�vd H � �vT� h xi�r,�y
�?�- �SG���/.P/��s . ,�'''i.J
�1�����/� �°�1P.i r�� ��%� :•._
6. BUYER'S NAME AND ADDRESS: �iQ h�,�j' L s G l L G/Q�r/ 5/�.x r
..� � .S.�i2i.riG.G��Gp 5 T
—_6,�'�.�..r,✓ T, .�A �.�i7 �
7• OTHER INFORNlATION REQUESTID:
Z�e Health Department wi11 provide:
1. Last four (4) years of septic pumping history; ��a/95� �3�,y�s 5� ,
2. Septic system location "AS-BUILT" card, if on file; �ov�-�- v
3. Septic system description;
4. Copy of Septic Disposal Application;
5. Percolation card, if on file (New houses since 1980); '
6. Review of engineered septic plan, if on file. ,
ALIAW TII�i (10) BUSINFS.S DAYS FROM DATE OP' SU�IITPAL FC7R T� HEALT9 DEPART� �O PROVIDE
II�MATION RHQOffiTED.
�1 QONIPLET� SSPTIC IlSSPF�TION P�D�RM. ATrA(� "AS-BUILT" IACATIQId CARD SUPPLIF.D BY T�
F�AL� DEPARTMENT. '
MAP A1�ID LOT NUNrlB�FR MU.ST Ai�SO BE PL� OTi T9L FRON'P PAC,L OF T� IIJSP�JCPI�T PCAtM.
BIC�I C�WATER USING THE USGS C�ID�NIATER ADJLIS� FORMULA MUST BE USED AL�ID SHO�FIN �T
�s� �. (ooP� a� FORr�i r�3r a� ogrAn� � � c� ao� aor�sszaJ, 362-3828.) '
NAME OF STATE CERTIFIED SEPTIC INSPECTOR: /�l��(,1�2D �f/�/.�j� :
ADDRESs: �D. �vY a 5'�
Gi'.ri�1,'O.�t./�L�:..� �1.� !'w+ � ��. ..I
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TELPHONE NUMBER: �DFI � 77�-1�/J�
FILING FEE.OF $10.00 PAID ON: � �� Printed o❑
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09/21/95 ReviGx� ��� �'aot•r