HomeMy WebLinkAboutISTS Permit
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,..:..' ~'~~;~IrAT~O;.F()i~I~~ ~~~:.~~::~:T SYSTEM (lSTS) PERMIT
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(N~te Al!Plicant: only fill out shaded sectioq below)
T ityl ~L
Proje ddress '-I '""'ill MI1..vh ',,(\ ",19 .sr N E
City/Zip 'P L. ' " -"" .
Site Evaluator '(<;,"'- . Installe~ '^ .
Septic Tank Size as per design submitted and approved'lY'~~''''<; 1000. ....... 1_0
Pump Tank Size as per design submitted and approved :7 '
Drainfield Size as per design submitted and approved (below)
.1M3 'I NC 1'Jt..
Date Received 6 -10" 0 L
Permit # I 1 A .2J""
Rec1 # ? ~-r.:z.s::.
Fee .-<,r(l
Receipt Code
New ISTS Replacement X-
Percolation Rates ~. /~ 1'7
Number of Potential edrooms . .y-
Depth to Restricting Layer 1:: t!fi- '
TOWNSHIP OR CITY USE ONLY
Are there any wetlands on property?
Wetland Replacement Plan attached
Recommend: Approval
Yes
Yes
Disapproval
No
No
Will any wetlands be impacted by proposed project? Yes No
LOU Exemption # Please attach copy of exemption.
Signature of Township or City Clerk
l\t
Date
.----.------- COUNTY USE ONLY
ISTS Setbacks: Building (tanks) -PL- (drainfield)2lL1 Lot Lines ~r ROWlEasement Lake/Creek/Wetland _ Wells ~I
Approved / Denied - By Scott County Environmental Health, subject to existing regulations and the following conditions:
1. Verify and maintain all required setbacks and elevatiOf1s. .
2. Protect (fence off) the primary and alternate d~illr~eIi:llocations while any building construction activity is occurring
on the site and maint~n fencing or some. ",.er'iI'pJrl'oved barrier if the drainfield could be damaged after instal!ation.
3. Install rock bed on contour and maintahl" at least 36 inches between the rock bed and the water table/mottling.
4. Protect sewer ~ine. ,l!;'!4 syste,W Mlm freezing.
5. Divert surf~e JVa~ aw~ from or around the drainfield area.. .
6. Sod or seed the area as s~on as possible upon completion to prevent soil e~on and damage to the drainfield (for late
season installations, hay or straw can be substituted until sodding or seeding l!an be done in the spring).
7. This permit is valid for 12 months from the date issued.
8. The property owner (or applicant, if different from the property owner) is responsible for assuring that the Installer
receives a copy of the final Department approved design.
9. Nonresidential ISTS shall include a water meter and, if a dosing device is used, an electrical event counter.
Signature ~
-m ~(1A ~K>
Date In -/3 -()~
White - County Yellow - Township
Pink. Applicant
Gold - Township
SCOTT COUNTY
INDIVIDUAL SEWAGE TREATMENT SYSTEM INSPECTION FORM
G;)wp, P,.rclr- 1--"1<9 _ Ins ectionDates i.,,~3o-"l{ / , PermitNo.I?-e-25"
Owner (;,"h}'1 (}"f" I II. Installed for (e orgpd) II Bus/lfdi'l>_
Project Address ~'i<fl( ...~' 0. ~t:. Designer Inslaller I$c')ki:l\"'"
City ~ _tOo c# 0 NEW Di1. REPLACE REPAIR 0 ADDITION
SETBACKS: ~BED OR GRAVELLESS L.EACHFIE~
Buildings to Tank ~ :! 6;1' ~\ Drop box concrete./~
Buildings to Drainfield 'f 7 ' ,It Trench Depth 7. .,,, Width J 6 I'
Well(s) setback&r 100' not installed ~ Trench Lengths .s l< 7 t\ ....
Lake/CreeklWetland - Trench Bottom Level
Property Line(s) - Trench Spacino /'-1 r
Dralnfield Rock Below Pipe
SEPTI /HOLDING TANK(S) l5zI New 0 Existing or Size of Gravelless Pipe
Uid Capacity 7; - / di)7:; Actual/ Expected Depth of Backfill
Tank Manufac~~ . ~ r/~ ....J Absorption Area: Square Feet
Baffle Type: ~ Fiberglass6Sanltary-T Concrete Lineal Feet
No. of Inspection Pipes " 4"/<<l'diam.
No. & Diam. of Manhole Access Z - 2., If
No. & Height of Manhole Risers ...1:;..ll." I - ,r6 "
r
.-
MOUND OR ATGRADE:
Percent Slope %
Dike Width up doWJ< side
Drainfield Rock Below Pipe'/ inches
Inches of Sand Below R~Ck upslope_downslope
Perforation Size & Spacin
Pipe Size and Spacino
Dimensions of Roc ed
Dimensions of S d Base
Depth of Flna over
ALTERNATE SITE AVAILABLE Yt,J
ENV HL TH APPROVED DESIGN ONSITE
.J5 See Notes added to Design Drawing
_ Drawing of System Below
,).;
jor
76 f'
701'
.':':-';"~
-e/no
12"
b-lf ..
6, (0 iJ /"6..1-
'1:10-
PUMP INFO:
liqUid Capacity
Tank Manufacturer ~ new / existing
No. & Height of Risers /
Pump Manuf. & Model No. ./
Horsepower ~
Feet of Head /Installed or as per design
Cycles Per Day / Installed or as per design
Gallons Per Cycle / Installed or as per design
Size of Discharge Line / 1.5" 12"
Type of Electrical H<)flf<up post & box by tank
Alarm Location / qarage / basement
Alarm: T~~~~ 1 Level Alarm I Other
Cycle co/"' & Water Meter (Commercial)
ALTERNATIVE / EXPERIM~NT AL SYSTEM:
Type ~
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NJ
1 ~y' I~
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'1'/- .:;- :J6':\"r'"
V~
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Inspector Comments: Divert all surface water awav from or around dralnfleld area. Sod or seed as soon as Dosslbl~
to orevent 11011 erosion.
Corrective Action Reouired:
I hereby certify, as the Installer. that the following tank openings were or will be constructed to be
watertight: Inlet, outlet, Inspection pipes and the access to the maintenance hole, Including risers.
_ (Installer InlUals)
Furthennore, I hereby certify. as the Installer, that the Individual sewage treabnent system was or will
be Installed In accordance with the Scott County Individual/ Community Sewage Treabnenl System
Ordinance No, 4, I agree to Indemnify and save Scott County hannless from slllols. damages, costs,
and charges that may be Incurred by the Cou because 0 ure n \0 and comply with
'In liaiion In ec\o(s Signature the provisions of this Ordlnsnce.
'AL COVER Insoector tv A r I . Installe(s Slonature
\ sys. tem is '1x1ln compliance 0 not In compllanc~ith the scbr60unty IndivlduaVCommunity Sewage Treatment
~ Ordina~ No.4, therefore, this document is a 1"\ Certificate of Compliance 0 Notice of Noncompliance.
White - County Yellow. Owner Pink -Inltaller
I hareby certify that based on this Inspection
and thelnfonneUon submitted by the slta
avalustorl aslgner, thalndlvldual sewage
treabnen tem ap rs to ba In compliance
with the Coun In IvlduaVCommunlty
Sewage e bnent S I m Ordinance No, 4,
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