HomeMy WebLinkAboutHALO BLK 2 LT 23
_, '~ t, '- REqUP. ST YOR' A??EOVAB OE
-' ~ INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate)
~' ~ama .of person requesting approval
2. ' %~ame of prope~y~ owner ....... /~/Y-Y-d~q .....
"':' - -
~, Nu~-.off..b~d~ooms in house J ,
5. Water, Anai~is:
a. Bactemial
b. Detergent
Well data:
a. Type
b. Depth..
c. Casing Size
de
Distance from well to closest existing or proposed:
1. Sewer line
2. Septic tank
' .. 3. Seepage Area
4. Cesspool'
5. Property Line
Other sources of Possible contamination, i.e., creeks, lakes,
houses, barn, drainage ditch, etc.
7. Sewage disposal system.
Age of system
Septic tank capacity in gallons
Name of septic tank manufactu~'r . ~'~_; !QQ~ ~!~2_- .
1. If "home made" show diagram on reverse side of this form.
Disposal field or seepage pit size and type (~ '< ~ ~/.
1. Distance to proper~y line to house foundation .
Pereolatio~l Test '~esults
f. Percolation Test performed by ,
~,, Use the reverse ,side of this form to show diagram. Diagram should include
-. /-~he foJlowing information: p~operty lines~.well location, house location,
~utic tank location, disposal area location, location of percolation test~
an~ direction of ground slope.
9. The ~fox.~tion on this form is true and correct to the best of my knowledge,
Signature of Applicant Date $ifned .......
TO BE FILLED OUT BY HEALTH DEPAP. T~,~ENT PERSONNEL
......... ~6'llowing con,]&lions i ~ '
Conditions
/ \ The above described sanitary facilities are disspproved for the following
reasons:
~ f ~ v &w ' ' /, ·
" App ova~is valid fop one year fo'llowing the date of approval.
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YlClNITY t~A~°
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