HomeMy WebLinkAboutCRESTWOOD LT 8 --- to R-IA.
(Fill out in Triplicate)
~_ ~ame -of person requesting' ~rov~l . .~D ..........
Ce
de
Distance from well to c osest existing or proposed
1. Sewer line ...... .
2. Septic tank ~ / .
3. Seepage Ama..//q / .
q, Cesspool'
5. Property Line
e
6. Other sources of possible contamination, i.e., creeks, lakes,
houses, ham, drainage ditch, etc. .
Sewage disposal system.
,?
a. Age of system /~ ,
b.' Septic tank capacity in gallons
c. Name of septic tank manufactum~
1. If "home made" show diagram on reverse side of this form.
~ , .
d.' Disposal field or seepage pit size and t~pe ~,~>~
- 1, Distance toprope~-.~ne /~. ~o house fo~dation ~
e. Percolation Tes~
f. Percolation Test performed by .
Use the re.verse..side of this form to show dta~ram. Diagram should include
..~he foilowlng Information: p~oper'cy lines; .well location, house location,
~~c tank location, disposal area location, location of percolation test,
a~ direction of ground slope.
The ~foTma~ion on this form is true and correct to the' best of my knowledge.
Signature of ppl a t' ~ Date Sizned
TO~ BE FILLED OUT BY HEALTH DEPART!.IENT PERSONNEL
~e above described sanitary facilities are hereby approved, .subject ,to the
........ ~l%owin~ cgnd~onsi ' "
Conditions: ,~,/?~Y~'
The above described sanitary facilities are disapproved for the following
Peason$;
of ~f~i~.~"~Al~ ~' '."', ,"'7...;i Date..'~'" ': ', , , :'~..~.I ~
"-. Approval is valid for one year following the date of approval.
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