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HomeMy WebLinkAboutCOLEMAN Block 2 Lot 2ri OC ~= REQUEST FOR APPROVAL OF ~I~)UAL SEWAGE AND WATER FACILITIES (Fill out in T~iplicate) 2. ~'N~e of p~ope~y~ owne~ . ~ ~ + .... Nu~=~f.~edm~ms in house~ -Water~J~¥~is: a. Bacte=im.l J b. Detergent Well data: b. Depth ......... c. Casing Size . Distance from well to closest existing or proposed: 1. Sewer line 2. Septic tank ~,, c""~'.,.,, ,., 3, Seepage Area~ ~.-j.~. . 4. Cesspool~ ~ . 5. Property Line 6. Other sources of Possible contamination, i.e., creeks, lakes, houses, barn, drainage ditch, etc. 7. Sewage disposal system, Se Age of system %~) . Septic tank capacity in gallons.~,c//~,~,z3/ , Name of septic tank manufactu~ ~z,4,.~ ~%,.~6/ ........... 1. If "home made" show diagram on reverse side of this form. Disposal field or seepage pit size and type 1, Distance.. to property-, 3_ine/,~, , ~, _ to house foumdatiom-~ ~. ~ -e. Percolatio~ T~s~ '~e-sults ~ f. Percolation Test performed ~~ ~Uso the re~erse ,side of this form to s)ow diagram. Dia~ra~ should include .... ~he fo~owl~ info~ation: p~ope~ty lines; .w~ll location, house location, ~ic tank location, disposal a~ direction of g~ound slope. The ~{-omtlon on this form is tmue and correct ko the best of my knowledge. SignatUre 'o~ ApPl'iCant' '~tt'e- S~fned TO BE FIr,L~D OUT BY ~EALTH DE?A~T~,~ENT PE~$O~N,,E,L · ' 'The above described sanitary facilities are hereby approved, subject to the Conditions: The above described sanitary facilities are disappPoved fo~ the following Peasons: · ,-' CPJ: cw