HomeMy WebLinkAboutCOLEMAN Block 2 Lot 2ri
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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