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, REQUEST FOR APPROVAL OF
I~DI'~DUAL SEWAGE AND WATER FACILI~I~
(Fill out in Triplicate)
~o. l~ame of pemson mequesting approval
5, Wat~[, Analysis: .
a.
a. ':
b. Depth ',
c. Casing Size
d. Distance from well to closest existing or proposed:
1. EeweP llr~e
7t
2. Septic tank
3. Seepage Ar, aa
4. Cesspool'
5. Property Line
houses, barn, drainage ditch, etc.
a. Age of system
b.
c. Name of septic tank manufactu, me~
1. If "home made" show diagram on reverse Side of this form.
d.' Dispos%l field,or seepage pit size and type
1, Distance to p~o~y, line to house ~undation
Other sources of possible contamination~ i.e., creeks, lakes,
?
Percolat ion~ Test
f. Percolation Test performed by ,
~-~- Use the reverse.side of this form to show diagram. Diagram should include
[~[~he fo]_lowing information: p~operty lines~.Well location, house location~
~o~!~qc tank location, disposal area location~ location of percolation test,
a~d direction of ground slope.
9. The ~-~o~t[on .on this form is true and correct to the best of my knowledge.
'S'%g~ature 'of Appllc~nt
.... bate Si~'ned '
FILLED OUT BY HEALTH DEPART~.~ENT PERSONNEL
?he above described sanitary facilities are hereby approved, subject to the
following con~'~ons
Conditions:
The above described sanitary facilities are disapproved for the following
reasons:
'" AppPova! lS~~'C:e year following, the date of
· - CPJ: cw
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