HomeMy WebLinkAboutELMRICH VILLAS #2 Block A Lot 7 Public Informationxx .
y. /3[ ,. ~ [1-141t ) REQUEST FOR APPROVAL OF
~ ~~, INDIVIDUAL SEWAGE AND WATER FACILITIES
' I ~ ~'~ (Fill out in Triplicate)
24''
of propertyr owner
Numbe.~. ~ bedrooms in house ...........
Analysis:
a. gacter~at
b. Detemgent
Well data:
a. Type
b. Depth
c. Casing Size
Distance from well to closest existing or proposed:
1. Sewer line ~
2. Sept~ c tank .
3. Seepage Area
4. Cesspool'
5. Property Line
6. Other sources of possible contamination, i.e., creeks, lakes,
houses, barn, drainage ditch, etc.
7. Sewage disposal system.
a. Age of system
b. Septic tank capacity in gallons -7~'-0~. ~ ~~ ~'~
c. Name of septic tank manufaetu~o~. ~ ......
1. if "home made" show dla~ram on reverse side of this form.
d.' Disposal field or seepaKe pit size and type
- 1. Distance to property line to house foundation
Percolation, Test~esults
f. Percolation Test performed by ~ ......... ~
Use the reverse side of this form to show diagram. Diag'ram should include
~he foilowing information: p~operty lines~well location, house location,
c~ptic tank location, disposal area location, location of percolation test,
and direction of ground slope.
9. The infor~tion on this form is true and correct to the best of my knowledge.
Signature of Applicant
"' ~te Signed
TO BE FILLED OUT BY HEALTH DEPAET~.~ENT PERSONNEL
-~he above described sanitary facilitieS are hereby approved, pubject to the
~-~61towing con~'ions:
Conditions: ..... /~/~)._~ ~
The above described sanitary facilities are dis¢~pproved for the following
re a$oIls:
Approval .is valid for one year following the date of approval.
CPJ: cw
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate)
~. ~a,,~ .of person requesting approval
2,~ ~fm~. of property, owner
N~b~. ~ b~4vooms in house
a. Baete~{a]
b. Detergent "" '
6. Well data:
a. Type .......
b. Depth_ ·
c. Casing Size
de
Distance from well to closest existing or proposed:
1. Sewer line
2. Septic tank
3, Seepage Area
4, Cesspooll-
5. Property Line
6. Other sources of possible contaminatiOn, i.e., creeks, lakes,
houses, barn, drainage ditch, etc.
7. Sewage disposal system.
a. Age of system
b. Septic tank capacity in gallons.
~000 Sf~X a 7S0
c. Name of septic tank manufactum~r ~,~a~te~ ,
1. If "home made" show diagram on reverse side of this form.
d.' Disposal field or seepage pit size and type~
1. Distance to property line to house foundation
e, Percolatio~ Test ~esults
f. Percolation Test performed by ..... ,
Use the reverse side of this form to show diagram. Diagram should include
,the following information: ~operty llnes~.well location, house location,
septic tank location, disposal area location, location of percolation test,
and direction of ground slope.
The information on this form is true and correct to the best of my knowledge.
Signature '6f Applicant
Date Signed
TO BE FILLED OUT BY HEALTH DEPART!.IENT PERSONNEL
~'The~ above described sanitary facilities are hereby approved, subject to the
........... ~$11owing cond~ions:
Conditions:
The above described sanitary facilities are disapproved for the following
re asoI1s:
Date
Approval is valid for one year following the date of approval.
CPJ:cw ,,