HomeMy WebLinkAboutNEVILLA PARK LT 84
INDIVIDUAL SEWAGE AND WATER FACILITIES (Fill out in Triplicate) '
Name .of person requesting appr. qval ..... /.~_.~-'F~..
a. BacteriaA
b0 Detergent.
..... 6, WeZ.Z data:
b. Depttl .... . - ' - *
Casing Size
Dis?nee fr~X~osest e×isting or proposed:
2. Septic tank ,
Cesspool~ ......
5. Property Line
houses, barn, drainage ditch, etc.
Sewage disposal system.
a. Age of system --!' -~ '~ ~ .'
Other sources of possible contamination~ i.e., creeks, lakes,
/ ,' 'i: ;': ,. '."
Septic tank capacity in gallons, /~ ~ ~_~ ,
1, If "home made" show diagram on reverse ~£de of this form.
Dis~qsa]. fleld om seepafe pit size and type~~L__
ppoper~y. ~ne~,~to house lo.clarion~ ~ ,
1.
Distance
to
e. Percolati~m~ Temt '~esults
he reverL, e ,s.~de of th.~s form to ' ' ' '
show diagram. D~agram should include
following information, p.~operty lines', .w~ll location, houoe location,
~ptic tank location, disposal area locatlon~ location of percolation test,
a~.~ direction of ground slope.
9. The ~for~at±on on this form is true and correct to the best of my knowledge.
~, ~Ignature of Appll ~ Date $zgned
T__O. BE FILLED OUT BY HEALTH PE}~SONNEL
_ .......... DEPAET!.~ENT
]e above
611owlng
Conditions:
described uanita~y facilities are hereby approved,
eon~i~ion~,,:
The above described sanitary facilities are disspproved for the following
~easons:
'--~roval is valid :flor one year following the date of approval.
· ,~ CPJ: cw