55 NE 97 St (6)ST TE OF G=LO O 1 1
DEPARTMENT OF HEALTH AND REHABILVTATOVE SE - V000 S
ONSITE SEWAGE AGE DISPOSAL SYSTEM CONSTRICTION AN •; INSTALLATION PERMIT
Applicant / _
7z , .25 s
PART 1 - SYSTEM IN TALLATION INSPECTION AN(lp (FINAL INSTALLATION APPROVAL
Installer , ��% ,��il Tank Manufactur N n
Proper tank legend: Yes : z No Tank material Tank level: Yes
Tankswatertight: Yes No Tank size - gallons gallons gallons
Proper tank outlet devic =: Ye
Draintleid Trench
Length Width Length Width
feet feet feet feet Length l0 feet x Y feet= 'c---) ft
feet feet feet feet Proper No. drainlines: Yes ---- No
feet feet feet feet Proper pipe separation: Yes'Ft> Yes' No
Total = ft Total = 2 -�� ft Distribution box level: Yes No
Systems located as permitted: Yes ---/No
Systems including plumbing stub -outs installed at proper elevation: Yes No
•
Other findings
Date / 27Approved by:
HRS —H Form 4016, Jan 86 (Replaces Feb 85 edition which may be used)
(Stock Number: 5744-002-4016-4)
Permit Number
Proper gravel size: Yes No Gravel is suitable quality: Yes No
PANT I I I - E O L L LLATOON APPIR1 VAL
Manhole or marker to grade: Yes No
Absorption Bed
Length 3C) feet x 5 feet
AN APPROVED INSTALLATION DOES NOT GUARANTEE PERFORMANCE
Average depth to drainpipe invert from finished grade: / T inches Maximum depth .R y Inches
Average depth of drainfield gravel: inches Minimum depth of gravel inches
Backfill or fill material as required: (Quality) Yes / No (Quantity) Yes — No
Inspected by A -g — zA-t -=- _ Date
COUNTY PUBLIC HE H UNIT
Note: Completed copies of this form will be provided to the applicant, installer and the building department.
Page 2 of 2
Work done by
Address of v
Owner
Septic Tank
Drainfield
Plumbing - Final
When ready
Received by
Date
Time
PLUMBING - INSPECTION
4
Gas
Permit
eiNel
Rough
AM
Top out
PM