NEW SYSTEM □RENOVATION □REPAIR ✗NEW CONSTRUCTION Date 7/5/2010

Name of Owner Kim Koopman Home Phone --- Site Address 18387 Boy Scout Rd Durango, Iowa 52039 Cell Phone 563-564-0017 Mailing Address 18387 Boy Scout Rd Durango, Iowa 52039

Legal Description: Township Center T89N Range RIE Section 4 CLIFFORDS ADD - LOT 1

BUILDING INFORMATION

Residential Dwelling: # of Bedrooms ___3___ # of Bathrooms ___2___ Garbage Disposal? ☐ Yes ☒ No Whirlpool? ☐ Yes ☒ No Water Softener? ☒ Yes ☐ No Walkout Basement? ☒ Yes ☐ No Basement Fixtures? ☒ Yes ☐ No If yes, drainage by ☒ gravity? OR ☐ pump?

Existing Septic Tank? X Yes ☐ No If yes, tank size? TO BE ABANDONED PER CODE

If yes, has existing tank been serviced and in good condition?

□Yes □No ___

Commercial Building: Type ___

# of Employees: ___ Design flow: ___ gallons per day. Fixtures in building: ___

MATED CUDDY V

WATER SUPPLY

Water Supply:

X Private Well New Well

X Existing Well

□ Public □ Community Well (# of homes _____)

Community Well (# of homes

I certify the above information to be complete and correct.

Kin Kodran 7/5/10

7/5/10

Signature Of Owner / Date

51. 2022. 2016. 2017. 2018. 2019. 2020. 2021. 2022. 2023.