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!P.- r. <br /> DiiiiiH, EXISTING SEPTIC SYSTEM DESCRIPTION <br /> ..co±+ <br /> Please answer the following questions as completely as possible,and to the best of your knowledge. <br /> 1. Your existing septic system consists of(check all that apply): <br /> @ Septic Tank 'Disposal Trenches 0 Capping Fill ❑ Sundfilter <br /> ❑ Seepage Bed 0 Cesspool or Pit 0 Unknown <br /> ❑ Other (Describe) Ni.-4 <, , <br /> gek4e <br /> 2. When was your septic system instilled? / `P� <br /> (Date) (Permit Number) <br /> _ <br /> 3. Tank material: ❑ Concrete 0 Steel ❑ Plastic or Fiberglass ra Unknown <br /> V <br /> 4. Septic tank volume(in gallons) kin he404,34 • <br /> 3. When vas the septic tank, last pumped`? Attach receipt if available. =' <br /> L . , F. 1e . <br /> 6. Number of disposal trenches ..,.. ole.11:x <br /> 7. Total length of disposal trenches (in feet) rr �'�' .-' ' <br /> 8. Do you propose to use the existing septic system? Yes ❑ NO <br /> 9. Is your septic system currently in use? Yes ❑ No rir If no, date of last use `h. , 20.2.0 <br /> 10. If the septic system currently serves a dwelling: <br /> How many bedrooms are in the dwelling? How many people occupy the dwelling? <br /> 11. How many bedrooms will be in the proposed dwelling? XL How many occupants? / <br /> 12. If the septic system serves a business: <br /> How many total employees are there? <br /> Type of business <br /> 13. Is there a proposed change of use of your structure (home or business)? Yes 0 No, . <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 know edge. <br /> i /. /2°22 , ..... (-•':::-(1-1:—, <br /> Malt) Signature of Property Owner or Legally Authorized Representative <br /> Office use only: Record of existing system: Yes 0 No 0 Attached 0 Date Issued <br /> Permit Number Certificate of Satisfactory Completion Issued: Yes❑ No❑ initials <br /> Other file information: <br /> 1 <br /> 1 <br />