HomeMy WebLinkAboutCREEKSIDE PARK #1 LT 57icl
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate)
~. Name ,of person requesting
2. ~'~ame of property.- owner
5.
Number-~£..bedrooms
~ate~3u~aly~ is:
b. Detergent
W~l] data:
Depth ·
Casing Size
Distance from well to closest existing or proposed:
t. Sewer line .
2. Septic tank _ .
3. Seepage Area
Cesspool'__
5. Property Line_..___.___.
6. Other sources of possible contamination, i.e.~ creeks, lakes,
houses, barn, drainage ditch, etc. ,, . ._..
Sewage disposal system.
a. Age of system / ~ ~__ ~.
b, Septic tank capacity in gallon
!
c. Name of septic tank manufactu.~e.~~.
1. If "home made" show diaFram on reverse side of this form.
d.' Disposal field or seepaKe pit size and t~e.__~ ~~_ _
1. Distance to prope~~ ~ne ~ ~ to house fo~dation
· e. Pe~cculatlo~l Te~t ~nesults ,
f. Percolation Test performed by ................. .
se the ~everse .side of this form to show diag_~am. Dia~ra~ should include
...~-~he following, information: p.~operty lines;.w~ll location, house location,
~p~cic tank location, disposal area location, location of percolation test,
a~ direction of g:.round slope.
9. The ~ort~a~io~ on this form is true and correct to the best of my knowledge.
; 'S'iKha"'t'ure' 'of Applicant ..... D~te si?-ne-d'
\,
TO_ BE FILLED OUT BY HEALTH DEPART!.~ENT PERSONNEL
~e above described sanitary facilities are hereby approved subjec~ to the
]~'ll~owin~ c,9.nd~ons i '
Conditions:
The above described sanitary facilities are disapproved for the following
reasons:
e approva 1.
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