HomeMy WebLinkAboutT14N R1W SEC 7 Portion of Lot 5LoT
INDIVIDUAL SEWAGE AND WATER FACILITIES
2.
3.
4.
5.
REQUEST FOR APPROVAL OF
Type
Depth.,
Casing Size
Distance from well to closest existing or proposed:
1. Eewer line
2. Septic tank
3. Seepage Area
4. Cesspool' ~OO1
a. Bacterial
b. Detergent
Well data:
b.
d.
5. Property Line
houses, barn, drainage ditch, etc.
Sewage disposal system.
a. Age of system
b. Septic tank capacity in gallons
c. Name of septic t~k manufactum~.. ,
1.
Other sources of possible contamination, i.e., creeks, lakes,
If "home made" show diagram on reverse side of this fomm.
d.' Disposal field or seepage pit size and type ,
1. 'Distance to propew~y line I~~ to house foundation
-e, Percoiat io~.
Test
f. Percolation Test performed by
Use the reverse.side of this form to show diafram. Diagram should include
-Zhe foilowing infor~nation: p~operty lines~.wetl location, house location,
~ptic tank location, disposal area location~ location of percolation test~
~ direction of ground slope.
The i~,fox~f~._lon on this form is true and correct to the best of my knowledge.
Signature of Applicant ' ' Date' Si~ned
TO BE FILLED OUT BY HEALTH DEPAET~JENT PERSONNEL
~'--[The~ above described sanitary facilities are hereby approved, subject to the
......... ~611owing con~ions:
Conditions:
The above described sanitary facilities are disapproved for the following
reasons:
~ Signature of ~era~.~ ..... .;. 'Date
Approval is valid for one year following the date of approval.
CPJ:cw