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HomeMy WebLinkAboutJOHN WELLS 1952 ADDITION BLK 4 LT 16LoT' ~[~ i i. ~[I REQUEST FOR A~'PROVAL OF INDIVIDUAL SEW~GE AND WATER FACILITIES (Fi.Il out in Name of person mequesting appmoval /i, i!3 ~,'/t/': f ~/ix ~ 3. 4. 5. ii- / Distance ir.om well to.closest existing or proposed: 1. S~wer~ l~ne 2. Septic tan~ / :"~? ~ 3. Seepage Azea 4. m-,.sspoor i !~) ~,i' 5. Property Line ..... . Other sources of possible contamination, i.e., creeks~ lakes, houses, baron, drainage ditch, etc. SewaFe d~aposal system. a. Age of systm,~_~:~i . b. Septic. tank capacity in c. Hame of septic tank manufact~? 1. If "home made" show diagr, am on reverse aide of this fomm. 1, Distance to pr©perry l_~n~ t:o house f,~madat~.o~ .e. PercQ]at:io~ Test f. Percolaliion Test pax'formed by ' , Use the reverse .side of this form to show alia'Tram. Diagram should include .?he following information: ppoperty lines~ ,well location~ house location, r~a.~tic ta~k location, disposal a~ea locatlon~ location of percolation test, a~ d]~ectio~ of ground slope. 9. The ]~t<,~t[cm ·on this form is true and correct to the best of my knowledge. SiFnature of Ap~'~ ' TO BE FILLED OUT BY HEALTH DEPART.~E[~T PERSONNEL ~The above described sanitary facilities are h~reby "" ...... ~6'].towin? co~],i.t~ons: approved, subject to th~__e The above described sanitary facilities are di[sapproved for the following Y'e &IS 011S ~ Signature of ~f~eza2.~ :' ,.' ;. · App~ual is valid for one year followin~ the date: of approval.