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07/21/2010 09:56 9524473982 KLINGBERG PAGE 01 <br /> x : X49 - tit'1to // iAo <br /> INDIVIDUAL SEWAGE TREATMENT SYS EM AS-BUILT FORM <br /> INSTALLER: et <br /> City/Twp, Date of Installation 7'-'c Q 7t Permit No. o/O —__663-1/42., <br /> _ <br /> Owner G..+" Installed for($ Bedrooms or gpd) ,S'" <br /> Project Address i� ' <br /> City 0r441J0 - <br /> WlEW 0 REPLACE 0 REPAIR 0 ADDITION <br /> SETBACKS: • TRENCHES,BED OR GRAVELLESS LEACHFIELD: <br /> Buildings to Tank b Drop box concrete t plastic <br /> Buildings to Drainfield �ae Trench Depth Width <br /> Weli(s)setback 50' or 100' 470 not installed Trench Lengths , /no <br /> Distance to Lake ----Creek '--Wetland Trench'Bottom Level_ yes <br /> Property Line(s)_ g Trench Spacing 1 -- <br /> , Drainfield Rock Below Pipe <br /> SEPTIC/HOLDING TANK(S) Ld New ❑ Existing' or Size of Gravelless Pipe <br /> Liquid Capacity . 'Ann (a- /.S®o' ` Actual/EXpected Depth of Backfill <br /> Tank Manufacturer_ - t) -Ga 4aj /Awl> Absorption Area: Square Feet <br /> Baffle Type: Plastic Fiberglass Sanitary-T Concrete Lineal Feet <br /> No, of Inspection es4"!6'�diam., 1 ',, <br /> No. & Dian of Manhole Access L_ T �y� ; ;PUMP INFO; <br /> No. & Height of Manhole Risers S""-. ' w Liquid Capacity /��0 <br /> Tanks 4 ft or less below Final Grade �y no : Tank Manufacturer ria` rlc existing <br /> lank Connections Sealed no No. &Height of Risers <br /> Tank/Riser Covers Sealed or above water fable a no Pump Manuf. &Model No. Cc G � <br /> MOUND OR ATGRADE: Feet of ead_ aaei <br /> Percent Slope _ / a' ` °/Q Cycles Per Day ' <br /> Dike Width If _up 4 down / 7 side Gallons Per Cycle, 124 5" <br /> Drainfield Rock Below Pipe • I inches Size of Discharge Line es <br /> Inches of Sand Below Rocky .. upslope downslope ; Type of Electrical Figokup o-B,pix b <br /> Perforation Size & Spacing Alarm.Location;- /6,It—' garage • = '+ <br /> Pipe Size and Spacing _Jig. '3 ' Alarm:Tank Alert/ veI Alarm IO <br /> Dimensions of Rock Bed l� X eeO,� ! Cycle Counter&Water Meter tnercial) <br /> Dimensions of Sand Base Si le Q! , <br /> Depth of Final Cover, !le <br /> iii4isvoetkircoo i-c <br /> IT <br /> DRAWING OF SYSTEM: „9 <br /> 1. <br /> 4 I` , <br /> 9d, r-- - <br /> 0 Olij <br /> al's ` . <br /> PRI I/VI-ra 7Z Act i <br /> _ f. <br /> Comments: _ <br /> I hereby certify,athe iclaller.That the Individual sewage I , w C ✓J�l��o � <br /> trealment system was installed In accordance with the Scott company Name , ' - • • 4.-- <br /> County Individual/Community Sewage Treatment System , q 5/rj�rf_a <br /> Ordinance No.4. / License Number n " (�/ Phone Number ,i�( *—� �7 <br /> Inctalloar's ---,12.02.---AV-1',..C'••,...`.',. 0 Address 1 0 f n; o k /-2._ <br /> I <br />