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a1-6bQ4 ' <br /> #111 <br /> ril ECE[iViE_ 1 1 <br /> TING SEPTIC SYSTEM DES c1 <br /> EXIS CRIPTI AUG 8 2021ti) <br /> OaecaN MARION! CA UN ILLY <br /> BUILDINGASPECTION <br /> Please answer the following questions as completelyp as ossible,and to the best of your kno <br /> 1. Your existing septic system consists of(check all that apply): Fill 0 Sandfilter <br /> Septic Tank Disposal Trenches 0 Capping <br /> ❑ Seepage Bed 0 Cesspool or Pit 0 Unknown <br /> 0 Other (Describe) <br /> 2. When was your septic system installed? !.t h ( (Permitxumber) <br /> • <br /> 3. Tank material: 0 Concrete Steel 0 Plastic or Fiberglass 0 Unknown <br /> 4. Septic tank volume(in gallons) 5.0.12 <br /> 5. When was the septic tank,last pumped? a 4 X — Attach receipt if available. . <br /> 6. Number of disposal trenches / <br /> • <br /> 7. Total length of disposal trenches (in feet) .?-o9' <br /> 8. Do you propose to use the existing septic system? Yes 0 No �-..i <br /> 9. Is your septic system currently in use? Yes ❑ No 21 If no, date of last use F- <br /> 10. If the septic system currently serves a dwelling. <br /> How many bedrooms are in the dwelling? 3 How many people occupy the dwelling? ,Z <br /> 11. How many bedrooms will be in the proposed dwelling? 3 How many occupants? 2 <br /> 12. If the septic system serves a business: j� <br /> How many total employees are there? �✓/I D <br /> Type of business <br /> 13. Is there a proposed change of use of your structure(home or business)? Yes 0. Now <br /> If yes,please explain • <br /> 14. Provide a plot plan(sketch)on the reverse side of this form showing the best estimated or actual . <br /> measurements that locate the existing septic tank and disposal trenches,property lines,easements,. ' <br /> existing structures, driveways,and water supply.Indicate the direction of north.If you are proposing to <br /> replace the septic system,indicate the test hole location. <br /> By my signature,I certify that the above information and the plot plan on the reverse side of this form are <br /> accurate and true to the best of my knowledge. <br /> 8 <br /> ©� ( ate l Signamre offropeity Omer or Legally AuthoIIzedRepresen ve <br /> Office use only: Record of existing system: Yes 0 No 0 Attached ❑ DateIssoed <br /> Permit Number Certificate of Satisfactory Completion Issued: Yes El No❑ hritia1s <br /> Other fileinfomiation: <br />