HomeMy WebLinkAboutT13N R4W SEC 25 N2N2NE4SE4 PTN (5),ase, s�r�
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REQUEST FOR. APPROVAL OF.._.
INDIVIDUAL SEWAGE AND 1i1ATER FACILITIES
(Fill out in Triplicate)
1_. Name of person requesting approval UA,,,, (�rit•_,��n�
2. .flame of property!owner�
3. Lega], description Loo D
4, Number of, bedrooms in house
5. Water, Analysis:
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a. Bacterial. r --
b. Detergent r.
6. Well data:
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a. Type _ 1J Y' \ 1X \ Q CA _•
b , Depth��
C. Casing Size til Jer /95
d, Distance from well to closest existing or proposed:
1, Sewer line
2. Septic tank
3, Seepage Area
4, Cesspool'
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5. Property Line
6. Other sources of possible contamination, i,e., creeks, lakes,
houses, barn, drainage ditch, etc,
7. Sewage disposal system. 0 2
a. Age of system
b. Septic tank capacity in gallons
c. Name of septic tank manufacturer
1, If "home made" show diagram on reverse side of this form.
d; Disposal field or seepage pit size and type
1. Distance to property line to house foundation
1.
e, PercolatioxL Test results
f. Percolation Test performed by
Use the reverse.side of this form to show diagram. Diagram should include
r,he foil.o•.ting information: property lines; •well location, house location,
.:ioi c tank location, disposal area location, location of percolation test,
ac.d direction of ground slope.
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9. T}.e s-, .,+;nn on this form is true and correc to the best of my knowledge.
i nature of Applicant
Pte ed
TO BE FILLED OUT BY HEALTH DEPAP.TtiENT PERSONNEL
The above described sanitary facilities are hereby approved, subject to the
.ol.].owi.ng conditions: —
Conditions: j, r
The above described sanitary facilities are disapproved for the following
reasons;
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7natu. e of `fic' c VCV..-`
Datd it ..A
Approval is valid for one year following, the date of approval.
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