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St G Panw F%3- zoo7_ I3 <br /> PAGE 1 OF <br /> TITLE, INDEX, AND PROJECT SHEET FOR POWTS PLAN SUBMITTAL <br /> Property Owner's Name Property Location <br /> �vi e r AAA,5-cd , 57 ( v, rerzt� <br /> Property Owner's Address Project Address(if different from Owner's) <br /> 9a( t3 U !t o (< JJ <br /> City& State Zip Code Phone Number Subdivision Name or CSM Vol&Page Lot# Block# <br /> -�n L-11:1--- 5 3i 3`1` cso; i-z `1" <br /> Type of Building ❑ City County <br /> or 2 Family Dwelling-No of Bedrooms 3 ❑ Village <br /> ❑ Public/Commercial-Specify Use- 9-Town of fql <br /> Effluent Type Filter Details <br /> a-Number 1 (Septic) ❑ Effluent(Type&Model) <br /> ❑ Number 2(Highly Pre-treated) ❑ Basin Used(Manufacturer&Size) <br /> ❑ High Strength Q-Inline(Type&Model)$ r,i p 4 sr F�c 2 <br /> Component Manual(s)Used(check all that apply) <br /> Gla Inground Soil Absorp.Ver 2.0 SBD-10705-P(N.01/01) ❑ Holding Tank Ver.2.0 SBD-10855P(N.03/07) <br /> ❑ Pressure Distribution Ver 2.0 SBD-10706-P(N.01/01) ❑ Other-Explain <br /> ❑ Mound Ver 2.0 SBD-10691-P(N.01/01) <br /> ❑ At Grade Using Pres Dist Ver 2.0 SBD-10854-P(N.03/07) ❑ Other-Explain <br /> ❑ Small Scale Waste Management Project Publication 9.6 <br /> INDEX �- ATTACHMENTS(List) <br /> Page 1 TITLE.INDEX.&PROJECT SHEET 7 p l Z J t u 4 <br /> Page 2 5-1; 4-e_ <br /> Page 3 Ce (( �r—% I TOTAL ATTACHMENTS <br /> Page 4 1 <br /> Seal of Designer,Architect or Engineer(If applicable) <br /> Page 5 I': �, r 4 - <br /> Page 6 cia'irrk <br /> Pagel f/'G rj. <br /> Page 8 /An G 2 ebit.4•11. /t <br /> Page 9 <br /> Other pages: <br /> Total Pages This Plan 3 <br /> I THE UNDERSIGED,HEREBY CERTIFY THAT THE <br /> PLANS AND SPECIFICATIONS SUBMITTED For Office use Only <br /> HEREWITH WERE PREPARED UNDER MY DIRECTION <br /> AND CONTROL AND THAT THE CONSTRUCTION AND <br /> INSTALLATION OF THIS POWTS WILL COMPLY WITH <br /> COMM 83 W.A.C.AND OTHER APPLICABLE <br /> REGULATIONS. rn <br /> Plumber: Cu(,e (--L ,QSr, <br /> Credential#: 220,4 -7y Date Z 7 <br /> Signature ,<_ � /�/ <br />