HomeMy WebLinkAboutSEPTIC PERMIT - M19-00019 - Jensen - 10468 Rig Ranch Rd - New SFRAPPLICATION -S bsurface Sewage Disposal
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i Site Fee: Date: ko
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Permit Fee; �� i 1�1� � iVt +� Document #: ,a3� � `�
Public Heath
Preve.nx_ Yro�lote, ��������. Receipt #: q ,�- (Official Use Only)
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Parcel #:fr�4,�'w�f,eA7y'f�Acres: a•
Property Address (If available): [`_IQ I/c", Ci
Legal Description: Township: t� la Ranger Section: County:
Subdivision:
Directions (nearest crossroad):
Block:
Applicant's Name:Date: Z?2/9
Mailing Address: . Tfe/ J% "&V ✓t-' Phone #: ZOO
City: State: _> Zip Code: 73 V/O
Applicant is: JdLandowner ❑ Contractor ❑ Installer ❑ Other:
Owner's Name: i` ,,-s�A/
Mailing Address: -5-30 S, J34'0 ��' Phone #: *Z&�V- 2 00 ��5 f
City:State: Zip Code: Y3 941 D
Type of Septic Installation: ;1 New ❑ Upgrade/Enlargement ❑ Replacement ❑ Tank Only
Proposed Usage: ® Residential ❑ Non-residential ❑ Other (i.e. barn, shop, etc.):
❑ Central (more than two dwellings) ❑ Large Soil Absorption (2,500 gal/day or ten or more dwellings) # of Units:
Is there an existing structure on this parcel? ❑ Yes IZ No Year Built:
Number of Bedrooms (residential only): s Number of Bathrooms: I
Number of People: Z-, Square Footage: t$/6 Garbage Disposal? ❑ Yes ®'No
Non -Residential Flow Design: Average [gallons per day (gpd)]: (> C Peak (gpd):
Foundation Type: ❑ Basement J&Crawl Space ❑ Split Level 0 Slab
Property is located: ❑ Inside City 9 Inside County
Zoning certificate or other county documentation submitted? ❑ Yes ❑ No ® N/A
City sewer or central wastewater collection system 200 feet or less to structure? ❑ Yes ;8 No
Water Supply: ❑ Private Well V9 Shared Well ❑ Public Water System, Number:
(Non -Public)
SIGNATURE:
DATE: �C>%
By my signature above, I`certify that all answers and statements on this application are true and complete to the best of
my knowledge. I understand that should evaluation disclose untruthful or misleading answers, my application may be
rejected or my permit canceled. I accept the responsibility to notify the Health District of any changes to the above
information if performed prior to completion of the permitted system. I hereby authorize the Health District to have access
to this property for the purpose of conducting a site -evaluation. I understand that this application and the subsequent
permit is non-transferrable between property owners and/or project sites. I understand that the application will expire one
(1) year from date of purchase. The permit, when issued, may be renewed if the renewal is applied for on or before the
expiration date.
Revision date 5/20/2010