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.