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REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate)
person requesting approval
descriptio[
Detemgent
Well data:
a.
b.
C.
d.
Depth ~j /
Casing Size ~ /!
Distance from well to closest
1. Sewer line ~ [
2. Septic t ank_~~/
or proposed:
4. Cesspool' --
5. Property Line ~9/~.
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 manufactu~'r
1. If "home made" show diagram on revise side of this form.
d.' Disposal field or seepage pit size and type
1. Distance to property line ~t
, ~ tO house fo.undation..._~-/...
Percolation. Test~esults
f. Percolation Test performed by i .... '
Use the reverse side of this form to show diagram. Diagram Should include
~the foilowing information: p~operty lines~.Well location, house location,
~6ptic tank location, disposal area location~ location of percolation test,
and direction of ground slope.
9. The information on this form is true and correct to the best of my knowledge.
Signature 'of App'lic'ant
Date Signed
TO BE FILLED OUT BY HEALTH DEPAP, T~ENT PERSONNEL
--The above described sanitary facilities are hereby approved, subject to the
.......... ~$~llowing conditions:
Conditions:
The above described sanitary facilities are disapproved for the following
reasons'
Date/~ ,' .
S~.a~e o'T ~f~ici;~?l~:~ .... ~.'
Approval is valid for one year following the date of approval.
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