Hubbard County Holding Tank Design
Date:
Property Owner:
Mailing Address:
City:
State:
Home Phone Number:
Zip:
Cell:
Site Address:
City:
State:
Zip:
Driving directions if no address issued:
Legal Description:
Sec:
Twp:
Parcel Number:
Range:
Lake/ River:
Twp Name:
Lake/River Classification: Select One
Reason for Holding Tank
Unsuitable Site:
Limited Use (<150 gpd):
Failing System:
Commercial Facility:
Tank Information
Number of Tanks:
Tank Sizes:
Alarm Type: Select One
Designer Name:
License Number:
Address:
City:
Home Phone Number:
State:
Zip:
Cell:
E-Mail Address:
Designer Signature: ___________________________________
Date:
______________________________________________________
**A SITE PLAN IS REQUIRED WITH THIS DESIGN**
**A SEPTAGE HAULING AGREEMENT IS REQUIRED WITH THIS DESIGN**
**A MANAGEMENT PLAN IS REQUIRED WITH THIS DESIGN**
Hubbard County Holding Tank Design
Property Owner:
Date:
Please Draw to Scale with North Arrow to top or Left Side of Page
Please show all that apply (Existing or Proposed):
Wells within 100 ft. of a Drainfield
Disturbed/Compacted Areas
Water lines within 10 ft. of a Drainfield
Component Location
Drainfield Areas
OHW
Boring Locations
Lot Easements
Elevations:
Benchmark Elevation:
Elevation of Sewer Line at House:
Tank Inlet Elevation:
Drainfield Elevation:
Access Route for Tank Maintenance
Property Lines
Structures
Setbacks
Pump Elevation:
Pump Discharge Elevation:
Restricting Layer Elevation:
Designer Signature: ___________________________________ License Number:
Date: