COUNTY OF DISBUQUE
DEPARTMENT OF HEALTH
ENVIRONMENTAL HEALTH DIVISION
13043 SEPTEL ROAD
DUBUQUE IA 5202
CONSTRUCTION PERMIT
CONSTRUCTION PERMIT
APPICATION
PRIVATE SEWAGE DISPOSAL
Applicant Name: Kim Koopman Property Owner Name: Same
18387 Boy Scout Durango 52239
(street) (city) (state) (zip) (street) (city) (size) (zip)
Legal Description: Lot 1 Clifford Add Section 4 Tornship Center Subdivision
Lot ___ Block ___ Subdivision
Class of work New Repair Extension Modify Replacement
Occupancy Residential Commercial Industrial Recreational Multi-Residential
Building or Structure Residential Dwelling Mobile Home Commercial/Office Bldg.
Type of Water Supply Private Well Shared Well Municipal Water Common Well
Lot Size 2.5 sq.ft __ areas Facility used Year/month Seasonality
No. of units to be connected / Estimated sewage flow 450 gpd
No. of units to be connected 1 Estimated sewage flow 450 gpd
No. of Bedrooms 3 No. of occupants 1 Building dimensions
Septic tank capacity 1250 gallons Material type Precast Manufacturer
Distribution box Yes ☐ No Material Type Plastic Drop Boxes Yes ☐ No
Gravity dosing ☐ Yes ☐ No Pressure dosing Yes ☐ No Dosing chamber size gals.
Description of construction: Gravel Dedding deep 4 pipe diameter
Total Linear Footage 0.32 width 500 ft
SPECIAL CONDITIONS Permit Fee Est. Construction Cost
Water Boilmer yes
Garbage Disposal no
Jacuzzi whirlpool tub
N.O.L
Special Approvals Reg'd Reg'd Not Reg'd
Zoning
Engineer
IDNR
DOT
Poro Test
Soil Boiling
Plan/Design
ENGINEER/CONSULTANT O.A Technician PROPOSED CONTRACTOR Schueller Concrete
I hereby certify that the above information is correct and that all proposed work will be completed in accordance with the Druque County Rules and Regulations regarding Private Sewage Disposal. I also agree to construct the system in accordance to the condition listed herein.
(X) Kim Hooh - 5/22/12
Applicant Agent Date
When properly validated below, this will serve as your permit to construct
Application approved By:
Plan/Report Revisited By:
Approved For Issuance By: