HomeMy WebLinkAboutHANSON ACRES #1 BLK 2 LT 11
~ INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicat~)~ ~-~ ._~-
person =equesting app=oval //~: ~~ . .
Number.of, bedrooms in~ house
~latezx Analysis:
a. Bacterigl.: ~' i
b. Detergent "
Well data:
b, Depth_ /~-7/
c. Casing Size
Seepage Area
Cesspool.'. ~7.t
Property Line
Distance from well to closest existing or proposed:
1. Sewer line ~
6. Other sources of possible contamination, i.e., creeks, lakes,
houses, barn, drainage ditch, etc.
Sewage disposal system.
a. Age of system 4Y~
b. Septic tank capacity in gallons
c. Name of septic tank manufactu~e.r
t. If "home made" show diagram on reverse side of this form·
Disposal field or seepage pit size and tS~pe ~ ~%g~-
....
1. Distance to pmoperty line ~l to house foundation ~'
Percolation. To'st
f. Percolation Test perfommed by
Use the reverse,side of this form to show diagram. Diagram should include
~'X%he foJLowing infommation: p~operty lines;.well location, house location,
~i~-Jc tank location, disposal area location, location of percolation test,
a~ direction of ground slope,
The h~£o.r,~m±~on on this form is true and correct to the best of my knowledge.
SSgnature of Applicant
Date Signed
T_qO BE FILLED OUT BY HEALTH DEPARTMENT PERSONNEL
above described sanitary facilities are hereby approved, subject to the
roi!owing con~'ionsi '
The above described sanitary facilities are disapproved for the following
reasons:
"'Signature Of ~.f,[ie.i;hl_...i ~ .... :]7 ~'i
Approval is valid for one year following the date of approval.
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