HomeMy WebLinkAboutNEVILLA PARK Block 2 Lot 68
~%~ v INDIVIDUAL SEWAGE AN~ WATER FACILITIES
~1~ ~ ' (Fill out in T~iplicate)
, ,~ / ~- ~ a~ of person requesting approva~
b. Detem[ent
Well data:
a. Type
c. Casing Size
d.
Distance from well to closest existing or prooosed:;~ ~'
2. Septic t:k~ ~ ~
4. Cesspool' ~
5. Property Line_ -~'
:x 6. Other sources of possible, contamination, i.e.~ creeks, lakes,
houses, barn, drainage d~tch, etc.
Sewage disposal system.
a. Age of system
Name of septic tank manufacturer
1. If "home made" show diagram on reverse side of this form.
Disposal field or seepage pit size and type
Distance to property line __to house foundation__~.____._.
h
e. Percolation..Te'st'~eaul~s
f. Percolation Test performed by
Diagram should include
Use the reverse .side of this form to show diagram.
roll.owing information: p~operty lines~.well location, house locatlon~
~pmlc tank location, disposal area location, location of percolation test,
ark direction of gmound slope,
The ~a,-fo~tlon on this form is true and correct to the best of my knowledge.
~, S~gnature of Applle'an't' Date $ig~'~'~
T._O__BE FILLED OUT BY HEALTH DEPARTMENT PERSONNEL
~T~e above described sanitary facilities are hereby approved subject to .,the
Conditions :~ ,
The above described sanitary facilities are disapproved for the following
reasons|
Approval is valid :for one year following the date of approval.
CPJ: cw
~ ~£V/LL,~
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