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1133 NE 91 Terr (5)[Lonen feet feet feet ,r otal = STATE OF FLOFI y EPAFRTMENT t F HEALTH AND REHA. BLITATBVE SE VICES ONSITE SEWAGE ISPOSAL SYSTEM CONST UCTION AN ENSTALCL ,T]O! PEA» An' Width feet feet feet ft Applicant d✓e ,e1/ 1.1/jv i/ '91, a000000000000000 A ' 0] -.SYSTEM IIhBSTALLAA EON INS /73;6 A./6: ?/ Cnstaller /4 ✓ 5 a c' • ?ropertank legend: Yes , to Tnkswatertight: Yes Proper tank outlet device: Yes V No rkeingieldl Tvonch Length feet feet feet Systems located as permitted: Yes No EMI E Tank material nefo Tank size: gallons Width feet feet feet Total = ft Systems including plumbing stub -outs installed at proper elevation: Yes _ No Average depth to drainpipe invert from finished grade G" inches ?roper gravel size: Yes u nspected by: � . _ 0000raceocsonocs0000000000rncoommoomormomaraoctoes0000nono Date ` !a approved by: \ H^S —H Form 4016, Feb 85 (Obsoletes previous editions which may not be used) (Stock Number. 5744 -002- 4016 -0) Permit Number '� / %: N AND FIN E.. NSTA'L1 ATPON Tank Manufacturer No Gravel is suitable quality: Yes T E 11 Fl S)TALI.,ATI9N APPROVAL Tank level: Yes gallons z: .c ns Manhole or marker to grade: Yes Ano©Pp`Ston o Length feet x �Zt 5 feet 4t2 2 F't Length feet x feet= Proper No. drainlines: Yes (V' No Average depth of drainfield gravel:ILL inches Minimum depth of gravel — inches No Date AN APPROVED INSTALLATION DOES NO7 GUARANTEE PERFORMANCE Proper pipe separation: Yes s No Distribution box level: Yes N Maximum depth ./ Inches 3ackfi:1 or fill mate rM as required: (Quality) Yes V No (Quantity) Yes '/ No Ot: ^er findings COUNTY PUBLIC HEALTH UNIT Page 2 o1 2 Note: Completed copies of this form will be provided to the applicant, installer and the building depar'_ :ent.