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<br /> MEM EXISTING SEPTIC SYSTEM DESCRIPTION'•
<br /> Please answer the following questions as completely as possible,and to the best of your knowledge.
<br /> 1. ..:','"
<br /> of(check all that apply): ' ''' '''.. -
<br /> VxistinSepetic Tangk-septic sYstera consists
<br /> psosal Trenches 0 Capping Pill
<br /> a.ieepage Bed 0 Cesspool or Pit El Unknown .
<br /> ..: .,. .
<br /> 0 Other (Describe)
<br /> i ..x.; 2. When was your septic system installed? 1 0/1.110).4-1 6)
<br /> permiortzzab.r)
<br /> . , .
<br /> , , ' 1
<br /> ... 3. Tank 'al: 0 Concrete Steel 0 Plastic or Fiberglass 0 Unknown
<br /> 4. Septic tank volume
<br /> (in gallons) i C,()f) - ' ;:•-,,',';'„]„,.;-&:,'„,,,,'L i: - 5 When was the septic tank last pumped? 11 a_ Attach receipt if available.
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<br /> 6. Number of disposal trenches
<br /> ... 7. Total length of disposal trenches cm feet)
<br /> . .,
<br /> .., 8. Do you propose to use the existing septic system? Yes
<br /> : "..-.. ,.
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<br /> 9. Is your septic system currently manse? Yes 0 No If no,date of last use
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<br /> 10. I21_ 7 ,
<br /> : * f the septic system currently serves adwelli
<br /> How many bedrooms are in the dwelling? --.< How many people occupy the dive]lingi? k rzt
<br /> , 1 1. How many bedrooms will be in the proposed dwelling? 3 How many occupants?
<br /> 12. If the septic system serves a business:
<br /> How many total employees are there?
<br /> Type of business
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<br /> ' . 13. Is there a proposed change tif use of your structure(home or busui. ess)? Yes CI, No 0
<br /> If yes,please explain
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<br /> : . 14. Provide a plot plan(sketch)on .the.reverse side of this form showing the bestestimedeoasr aemctualents,
<br /> •
<br /> measurements that locate the=sting septic tnnir and.disposal trenches,propertylines, .
<br /> " eways,and water supply.Indicate the direction of north.If you are pitipOcrng tO
<br /> reex:latifegthestruscturepticess'ydstem,n17 indicate the test hole location_
<br /> By my-signature,I certify that the aboveirtforrnation and the plot plan on the reverse side of this form are
<br /> accurate and true to the best°fray knovvi edn.
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<br /> OUlce use oniy:Record of criming vtqui.•Yes p. N.0 An...bed, 6 iss.,4,0 yr'!!1)...Er
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