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NAME Twr Ile eNON <br /> ADDRESS <br /> FIRE #/ROAD NAME A 3J S- ce R® <br /> LEGAL DESCRIPTION s d r Too v /2 /g w <br /> COMPUTER # 0/300 <br /> - TANKS <br /> MFG w.c. P TYPE Gonc. SIZE /Po a- 4660 <br /> BAFFLE CONDITION aaa <br /> MANHOLE COVER CONDITION <br /> COMMENTS <br /> - DRAINFIELD/DRYWELL <br /> SIZE A'g -.50 , TOTAL SQUARE FEET 600 <br /> SYSTEM ELEVATION <br /> BENCHMARK <br /> - IS SYSTEM: <br /> BACKING UP INTO STRUCTURE YES/NO No <br /> DISCHARGING TO SURFACE YES/NO No <br /> DISCHARGING TO GROUNDWATER OR SURFACE WATER YES/NO ND <br /> - SOIL BORING VERIFICATION (provide on CST Soil Report) <br /> �- PLOT PLAN (must provide plot plan showing location of existing septic tank, <br /> drainfield, well, lot lines and other related. setbacks. <br /> K ' <br /> If the existing system is undersized, indicate whether or not a replacement <br /> area is available. <br /> Name Jr90)�5 .S. omn/'-- 1 Lic. # o 73`r4o <br /> (please print) <br /> SignatureDate <br />