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INDIVIDUAL SEWAGE TREATMENT SYSTEM AS-BUILT FORM <br /> INSTALLER: &Rq WgLL V�l LTJ KQ Co <br /> City/Tw . (/an D Date of Installation Permit No.-Po (Q_,�jZ+ <br /> Owner Installed for(#Bedrooms or gpd) <br /> Project Addr ss <br /> City dvOVi D )j NEW [:] REPLACE ❑ REPAIR ❑ADDITION <br /> SETBACKS: , TRENCHES, BED OR GRAVELLESS LEACHFIELD: <br /> Buildings to Tank D box concrete/plastic <br /> Buildings to Drainfield Trend th Width <br /> Well(s)setback 50'or 100' //( not installed Trench Leng <br /> Distance to Lake l' Creek Wetland .� Trench Bottom Le yes/no <br /> Property Line(s) Jr.n�.- Trench Spacing <br /> Drainfield Rock Below Pipe <br /> SEPTIC/HOLDING TANK(S) C9 New ❑ Existing or Size of Gravelless Pipe <br /> Liquid Capacity 9-SQ IQ20 Actual/Expected Depth of Backfi <br /> Tank ManufacturerAbsorption Area: Square Feet <br /> Baffle Type: Plastic Fiberglass Sanitary-T Concrele Lineal Feet <br /> No. of Inspection Ipes4" lam. <br /> No. & Diam. of Manhole Access dq 1 PUMP INFO: <br /> No. & Height of Manhole Risers Liquid Capacity <br /> Tanks 4 ft or less below Final Grade s Y no Tank Manufacturer SaIfAlt existing <br /> Tank Connections Sealed e /no No. & Height of Risers /-41-1 <br /> Tank/Riser Covers Sealed or above water table_<yes no Pump Manuf. &Modyl No.Ga�ti , . 3871 <br /> Horsepower y _AL GPM 17. <br /> MOUND OR ATGRADE: Feet of Head / <br /> Percent Slope S % Cycles Per Day <br /> Dike Width up down side Gallons Per Cycle /74 <br /> Drainfield Rock Below Pipe inches Size of Discharge Line 1.5" <br /> Inches of Sand Below Rock upslop downslope Type of Electrical Hookup ost& ox a <br /> Perforation Size&Spacing Alarm Locat' seen <br /> garage m <br /> Pipe Size and Spacing % S- Alarm-1ank Ale /Level Alarm/Other <br /> Dimensions of Rock Bed ,.L Cycle oun er&Water Meter(Commercial) <br /> Dimensions of Sand Base X 9p <br /> Depth of Final Cover /$ /-0 1,2..11 <br /> DRAWING OF SYSTEM: <br /> 10t <br /> Comments: <br /> I hereby certify,as the installer,that the Individual sewage ,r 'A/ �}� n <br /> treatment system was installed in accordance with the Scott Company Name 0 �"'CLL L.Jt;,lt L 11461 GO <br /> County Individual/Community Sewage Treatment System R52.445_ 001 <br /> M <br /> Ordinance No.4. License Number �r Phone Number <br /> Installer's Signature �6�fi�� Address N550 I R A94-1 Ne <br />