HomeMy WebLinkAboutNELS KLEVEN Block 10 Lot 3
REQUES~ FOR APPROVAL OF
_ INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate)
~./..~.-~ }~ame of person requesting approval
4. Number oq bedrooms in house ~~/ ,, ~N' ~
d. Distance f~om well to closest existinE o~ ppoposed:
2, SeptJ c tank
Other sources of possible contamination, i,e., creeks, lakes,
houses, barn, drainage ditch, etc.
3, Seepage Area
4, Cesspool'
5. Property Line
6.
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 reverse side of this form.
d.' Disposal field om seepage pit size and type
1, Distance to property line to house foundation
e., Perco] ation. Test
f. Percolation Test performed by
Use the reverse .side of this form to show diagram. Diagram should include
""~he foil.owing information: p.roperty lines~ .well location, house location,
~;v~qc tank location, disposal area location, location of percolation test,
aad d~rection of ground slope,
The ln~.~om on 'this form is true and correct to the best of my knowledge.
Signature of Applic~'~ Date S1gned
TO BE FILLED OUT BY HEALTtt DEPA?,TUENT PERSONNEL
T e above described sanitary facilities are hereby approved, subject to the
~ollow~n? con~.t'ions:
Conditions
The
above
described
sanitary{- facilities are disapproved for the following
reasons:
Approval is 9/a.].id for one year following 'the date of approval.
CPJ: ew