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HomeMy WebLinkAboutSOLAR ESTATES LT 6�IQY �n�1��-f. f � � �� �r � � �� '�.m-- ' �'`ti s `�. { � � � „sees � a' ,_. J " REQUEST FOR AP7M7A'U OF 44 III INDIVIDUAL SEWAGE AND WATER FACILITIES (Fill out in Triplicate)` "i Name of person requesting approval �L'4.c•� ��1./.�e' 2. Name of property owner 3. Legal des 4. Number of _bedrooms in house 5. Water:Analysis: a. Bacterial b. Detergent 6, Well data: a. Type r b. Depth c. Casing Size 64? ,, p/ d. Distance from well to closest existing or proposed: f0i 1. Sewer line 2. Septic tank_. Ps- , �(r 3. Seepage Area. 4, Cesspool'�� c L f 5. Property Line , 6. Other sources of possible contamination, i.e., creeks, lakes houses, barn, drainage ditch, etc. , 7. Sewage disposal system. 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 �r I e, Percolation, Test 'results f. Percolation Test performed by ,-q-.Use the reverse side of this form to show diagram. Diagram should include the following information: property lines; -well location, house location, Otic tank location, disposal area location, location of percolation test, and direction of ground slope. 9. The h;for,ration on this form is true and correct to the best of my knowledge. I Signature of Applicant Date Signed TO BE FILLED OUT BY HEALTH DEPARTMENT PERSONNEL The above described sanitary facilities are herehy approved, subject to the ollowing condit-ions: Conditions: a The above described sanitary facilities are disapproved for the following reasons: Signature of ffficiaijj.; Date Approval is valid for one year following the date of approval. CPJ.cw � OF HEALTH AND WELF a RE 2W Lab. ADHW - LAB - DEr RTMENT OF PUBLIC HEALTH DIVISION BACTERIOLOGICAL WATER ANALYSIS OFFICE DAT � /j VL Records in this office indicate this WATER SUPPLY to be of: ❑INDIVIDUAL OTHER E3 Satisfactory El Questionable [I Unsatisfactory Sanitary Status. PUBLIC SEMI-PUBLIC REPORT RESULTS TO Anolysis.shows this Water SAMPLE to be: NAME Satisfactory ❑ Questionable ❑ Unsatisfactory. ADDRESS �© If an "Unsatisfactory" or "Questionable" status is indicated above below. you should fake immediate action as recommended is Boil or chemically CITY 1. Notify consumers water polluted. this water as outlined in the enclosed leaflel MI^ ,✓l" ' treat ADDRESS .��T'✓rY "Drink It Pure." OF SOURCEC� ' 2, Increase chlorination sufficiently to meet recommended residual standards necessary to maintain F�� COLLECTED BY Determine source of contamination and take action SAMPLE pm TIME COLLECTED Tap a safe water supply of all times. lorinafion and other mechanical equipment. Make certain i'f is /¢ Basement DATE COLLECTED c en Tap ❑ Bathroom Top 3. Check ch , functioning property. Sample Collected From disinfecting residual is not obtained, p lease [I Other (List) s 4. II after checking equipment a wire this office For emergency assistance or advisory services. • • subject to pollution by man and animals. ❑ ❑ Drilled gored __S. This is a surface water source and wafer supply source should be developed. Driven Well ❑ ❑ ❑ Cistern ❑ Other An approved ❑ spring ❑ dug well ❑ driven well 9 SOURCE: Brick or 6. Improve your Dug Well or Cistern Coon: ❑ Concrete ❑ Metal ❑ Tile ❑ drilled well ❑ cistern. Walls - ❑ Wood Concrete Concrete ❑Metal ❑ Open Top well to a sale location in relationship to your sewn ge Top - ❑ Wood ❑ Basement Offset ❑ Under House 7. Relocate your disposal system. ❑ see enclosure LOCATION: ❑ In Bas ❑ In YarOther 7RD should not be over 48 hours o of Septic _Feet. Building SeFeet. Tonk 8. Sample too long in transit; sample to indicate reliable results, please send new sample. DISTANCE TO: or Other DPipe Feet, SeFeet. Pool Feet. Privy ezaminafion ❑ Bottle Broken in transit, p lease send new sample. Tile Field Feel. Pi Other Possible Asbestos Sources of ContaminationCost ❑ Fib,. ❑ 9. Contact your nearest - El Local Health Department or ❑ Alaska for bulletins, consultation and SeweCost❑ Woad ❑ Tile Cement Division of Public'Heahh, sonilafion office MATERIAL: Building assistance. ❑ plastic joint MateriTYPO ❑ Na ❑ Yes SAPIITARIAN'S REMARKS GENERAL: Does Water Become uddy or Discolored? when? Depth Diameter of Well Depth ]et. Well Casing Diameter Wafer Depth Length o Length of From BottomIn Uti Drop Pipe Offset In ❑ In Basement ❑ Room ❑ PUMP LOCATION: ❑ In Well Basement On Tap E3 OI Well ❑Other ❑ No ❑ Yes -- PURPOSE OF EXAMINATION: Illness Suspected? Repair, El No ❑ irs to System? EJ Yes New Source of Supply? 11 Yes No Signature