HomeMy WebLinkAboutT13N R3W SEC 13 LT 1 OF 64T13N R3W
Sec 13
Lot 1 of 64
#006-045-24
"~ lt,~n'~-.of person requesting approval
2. ~lan~, Of property owner.
g. Number'st bedrooms in house
5. Water Analysis:
a. Bacterial .
b. Detergent ""' .
6. Well data:
a. Type .
b. Depth
Casing Size
Distance from well to closest existing or proposed.
1. Sewer line ..... . '
6. Othe~ sources of possible contamlna~ion, ~.e.~ c~eeks~ lakes~
houses~ ba~n, d~ainaEe ditch, etc. .
Sewage disposal system.
a. Age of system ~, .
b. Septic tank capacity in gallons
c. Name of septic tank manufactum~r
1. If "home made" show diagram on reverse side of this fo~m.
d.' Disposal field or seepaKe pit size and type
1. Distance to property line
to house foundation
· e, Perco]ati~T~s~
f. Percolation Test performed by
Diagram should include
Use the reverse side of this form to show diaEram.
.-~he following information: ~operty lines;.well location, house location,
~ptic tank location, disposal area location, location of percolation test,
a~ direction of ground slope.
The i~rfox~rm~ion on this form is true and correct to the best of my knowledge.
~t~re-df Applic~ Date Sifned
TO BE FILLED OUT BY HEALTH DEPAP, T~.IENT PERSONNEL
~he above descrzbed sanitary facilities
........ '~llowin~ cond~ions ~ ']
are hereby approved, subject to the
The above described sanitary facilities are disapproved for the following
reasons:
Appr6val is valid for one year following the date of approval.
CPJ: cw