HomeMy WebLinkAboutHANSON ACRES #1 BLK 2 LT 10
_ INu£VIDUAL SEWAGE AND WATER FACILITi£S /0 t~
of person requesting approval,
data:
d. Distance- from well tO closest e×lsting or proposed:
1. Sewer line ~fp !
2. Septic
3, Seepa~'e Ar. ca
4, Cesspool'_
5. Property Line
6. Other sources of possiZle contamination, i.e., creeks, lakes,
houses, barn, drainage ditch, e~.~ .... --~ ........
7. Sewage disposal system.
a. Age of system ,-~/'~L~/ ·
b. ept~c tank capacity in gatl~ns_
c. Name of septic tank mahufactu~,
1. If "home made" show diagram on reverse ~ide of this form.
- .1. Distance to p~pe~ ~.~_ ~ ~ ' to house foundatio , .~
· e, Percolatlo~ Test ~snlts
f. Percolation Test performed by
Dia¢ram should include
4. Use the reverse.side of this form to show diagram.
· --[~%he foJ~lowing information: p~operty lines~.weli location, house location,
m~Utic tank location, disposal area location, location of percolation test,
an~ dir.ection of ground slope.
9. The tn-~o-~tion on this form is true and correct to the best of my knowledge.
Date Signed
~Signature of Applicant
T__O0 BE FILLED OUT BY HEALTH~ DEPART!.~ENT PERSONNEL
~e above described sanitary facilities are hereby approved, subject to the
.......... ~61!owing condi%lonsi
Conditions:
The above described sanitary facilities are disapproved for the following
re~sons:
Approval is Vali~ for one year following the date of approval.
CPJ: cw