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: