HomeMy WebLinkAboutALPINE VILLAGE BLK 5 LT 8A
INDIVIDUAL SEWAGE AND WATER FACILITIES
a. Bacterial
b. Detergent "" .
Well data:
a. Type_
C. Casing Size _ ~f~ .
d. Distance from well to closest existinE or proposed:
1.
2.
3.
4.
5.
6.
S,wer tne
Septic tank·
Seepage Area ---' .
Property Line .... ~/..
Other sources of possible contamination, i.e., creeks, lakes,
houses, barn, drainage ditch, etc.. ..... --7' . ·
Sewage disposal system.
a.
b.
Age of system~
Septic tank capacity in gallons~~__~.
c. Name of septic tank manufactu.~.~.r ..... '--7, .. ............ .
i. If "home made" show diagram on reverse side of this form.
d.' Disposal field or seepage pit size and type
- I. Distance ~o psope~y line to house foundation ~~.
Percolatioo, Test '~esults ,,
f, Percolation Test performed by.,. ~ . ......... . . ,., ,
Use the reverse.side of this form to show diagram. Diagram should include
"-~he foilowlng information: ~operty llnes;.well location, house location,
~pt{c tank location, disposal area location, location of percolation test~
a~ direction of ground slope
g. The lz-~f~wm~ion on this form is true and correct to the best of my knowledge.
'Sig6~t'u~e 'of Applicant'
Date S~gned
TO BE FILLED OUT BY HEALTH DEPARTMENT PERSO,~,NE~L
~T~e above described sanitary facil~tles are hereby approved, sU~bje~c~ t.9 t~he
~_~l!owin ~, conditionsi .....
Conditions:
The above described sanitary facilities are disapproved for the following
reasons:
¥~rafls A~ninistration
Sox
A~choratp) At&~k~ ~0501
~Ct~ 8m~r ~ad W~r Syst~J
~r I~ 8, 81o~k S, AlpirJ Vill~
~di~si~ (7324
7-7'0
Siv~ pe~ng t~ esc~ o~ f~s
c~loCely ~ s~ sys~ to ~ l~ttl6 prior to J~y
t~ly ~' fr~ ~ woll ~ s~Id be ~vad in
Water is m~li~ via a I~' ~ which was foumd, by this
~p~, to h~ s~isf~ ~l~ o~ Ch~ before mu-
Stm:~roly,
£~.IFFORD P. ~INS, R.S.
John
