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t� E 3 R ^.S•K,N
Good Life, Great Resources.
OEM OP SNY19ONMENY AND C -ROY
fy*tt or 7)e
Owner First Name
System Registration r Onsite Wastewater 12-013
Ver. 4/2020
Treatment Septic
Initial Last Name
140�t-SS3- 3` 1� I
Owner Phone Number
Business or Legal Entity Name (if applicable)
Owner Mailing Address City State Zip
Physical address of system if different from owner's mailing address
Location smar&� iiqn
Wil Coni Lia+p d
r/a '/4 Section Township Range CountjJ
OR Geonravfiicd coor6utdies to 4 dacLmaCpoints
Latitude
Longitude
Mark One U; Dwelling ElNon-dwellingPrevious system registration number (if applicable) TS
ERN'ew system ❑ Modification of existing system [❑ Tank only ❑ Trench only] ❑ Inspection only
❑ Temporary modification (Describe problem causing discharge and reason for temporary modification):
Design flow Q0 gaUday # of Bedrooms' Depth to seasonal high groundwater ` feet
Percolation rate 1,4 , q (,l min/inch Loamy sand liner installed* ❑ Yes ❑ No
7Se tic tank capacity gallons Septic tank Manufacture/ Model* S n � (i o r Ne G) WZ1 ru hen
J Garbage Grinder* ❑ Large capacity tub* Number of trenches Width of trenches (J ( inches
Total length of all trenches feet Total effective trench bottom area 69 > 0 sq. ft.
Soil Absorption System Description (Select one of the following):
❑ Gravelless chambers without filter material (inside bottom width of chamber
Make and Model of chambers installed
❑ Gravelless chambers with filter material (describe filter material
Make and Model of chambers installed
❑ Pipe with filter material (describe filter material
❑ Gravelless pipe without filter material (diameter of the gravelless pipe
❑ Gravelless pipe with filter material (describe filter material
❑ Bundled expanded polystyrene synthetic aggregate without filter material (bundle diameter
inches)
inches)
in.)
❑ Bundled expanded polystyrene synthetic aggregate with filter material (describe filter material )
210ther (describe)
I swear or affirm that the system complies with Title 124 requirements and that the registration information and
documentation submitted are true, complete and accurate.
I K 11 10S-1
:(Printor Type) F' arae Initial Last Name Certificate/License Number
CC ct- 19
Signature o fled Professional, Professional Engineer, or Registered Date of Inspection or Completion of Construction
Environmental Health Specialist
NOTICE: Failure to complete the form or include the appropriate fee(s) will delay the registration.
(*) Indicates item requested/ not required on reg;stration
Nebraska Department of Environment and Energy. PO Box 98922, Lincoln NE 68509-8922
Lincoln -Lancaster County Health Department
n. Environmental Public Health Division
3131 N Street o Lincoln NE 68510-1514
DEPA�E Phone: 402-441-8643
[PeCrmit Number:
- ,Oa l
Onsite Wastewater Treatment to
As -Built Description and Drawing -
Type of Onsite Wastewater System: ElLagoon (Skip to Back Page) M Subsurface Septic ❑ Mound
Onsite Wastewater System Location p
Address or Legal Description or Parcel identification Number (PID)
Owner: pr t �Yi Address �P�r�[ e
A. Wastewater Piping
1. Material: P V C Rchedult lit? Diameter: 4 in.
2. Distance between dwelling and septic tank: 05 ft.
B. Septic Tank su d er
1. Material k &GM t,
1 `
2. Capacity: 1500 QnJ 10n'
3. Depth to top of tank, below unfinished grade: of a. in.
4: Distance to:
Well 15 ft.
Pressure'line '75 ft
Property Linel5'O ft.
Foundation a5 ft.
C Distribution Box or Drop Box
Distance and Direction from septic tank: S ft. q
D. Drainfield/Absorption Field
5" Trench ❑ Bed
1. Type: ❑ Perforated Pipe ❑ Chamberless Q Other
Material brand and inside width of Chamberless:
EZ Flo Rta
2. Number of Laterals: .1
3, Length of each lataral (linear): ft. /U P ft. 40
ft. ft.
4. Drainfield size: (o 3 O sq. ft.
5. Distance to:
Well
Pressure line
Property line -h IGO ft.
Depth of Groundwater * .
Was the Onsite Wastewater System covered prior toi-L-eHE3 nspection? ❑ Yes R"'No
81ai r ,.
If Yes, the Certified Professional must sign below for final approval:
I swear and affirm that the system complies with Lincoln Municipal Code (LMC) 24.38 and/or County Resolution
R-13-0062 requirementwand that the information and documentation submitted are true and accurate.
Certified Professional Signature:
Date:
Complete As -Built drawing on the back of this form.
Updated 2/18
Indicate North
W/ Arrow Here:
Onsite Wastewater System Design (Example)
Well
House
Min. 30'
Cleanout Min, 15' 1
m
[E
Septic Tank Min. 75' '
I . z Va eta1 a,
Level trench botto percolation CeS�A�ea
fi
`Note -If Lagoon, show all applicable dimensions
1
I
t
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