HomeMy WebLinkAboutT12N R4W SEC 2 LT 15 S2
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate~
%Iame .of person requesting approval
2.' ~a~ Of property~owner
3. h~gal descmiptio%
4. Numbex~-.o~ ~edmooms in house
5. Wate~ Analysis:
a, Bact =~rzgl
b. Detergent
WeLl data:
Depth_
c. Casin~ Size,,,
d.' Distance from well to closest existing or proposed:
1. Sewer llne /~ /
2. Septic tank ~--'3 /
3. Seepage Ar, sa ~' /
5. Property Line , .
6. Other sourcesof posszo!?' ..... contamination, 1,e.~ creeks, lakes,
houses~,barn, drainage ditch, etc. ~/d~/~ .
Sewage disposal system.
b.
Age of system /bLE~t.4~
Septic tank capacity in gallons,
Name of septic tank manufacturer
If "home made" show diaEram on reverse side of this form.
Disposal field or seepage pit size and type
1. Distance to proper~y line ~ / to house foundation
e, P ercolation~, T~st ~esults
f. Percolation Test performed by
Use the reverse .side of this form to show diagram. Diagram should include
'~he foilowing' '
znfobmat~on, p~operty lines~.well location, house location,
'~:{c tank location, disposal area location, location of percolation test,
a~ direction of ground slope.
9. The ~-£o~-~rm~ion on this form is true and correct to the best of my knowledge.
gnature of Applicant
Date Signed
T__O BE FILLED OUT BY HEALTH DEPART[-~ENT PERSON,NEL
~--]'The~ above described sanitary facilities are hereby approved, pubject to the
........ ~$'llowing con~ons:
Conditions:
~The above described sanitary facilities are disapproved for the following
reasons:
Date ~ ~t' ~ /
Approval is valid for one year following the date of approval.
CPJ:cw