HomeMy WebLinkAboutCREEKSIDE PARK #1 LT 11K
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REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
~a~-of person requesting approval., . {J, , ,
5. Water_Analysis:
a. Bacte~iaC[
b. DetePgent
6, We]] data:
a. Type
b. Depth
c. Casing Size
Distance from well to closest existing or proposed:
1. Sewer line .
2. Septic tank
3. Seepafe Area
4. Cesspool' .
5. Property Line
Sewage disposal system.
a.
b.
Septic tank capacity in gallons
Other sources of possible contamination, i.e., creeks, lakes,
houses, barn, drainage ditch, etc.
Name of septic tank manufactu~e.r
1. If "home made" show diagram on reverse side of this form.
Disposal field or seepage pit size and type ,,~ ~ <~ ~ ~
1. Distance to proper~y line lq tO house foundation
Percolation Te~tTesults
f. Percolation Test performed by
Use the reverse.side of this form to show diagram. Diagram should include
'.'~he fei. lowing information: p~operty lines~.well location, house location,
~trtic tank location, disposal area location, location of percolation test,
an~ direction of ground slope·
· this is true ~d.~o?~ect to the j~st of my knowledge.
~ ~/(Sifnotur '
', ~plic~t ~ Date Signed
TO BE FILLED OUT BY HEALTH DEPARTMENT PERSONNEL
~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.
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