HomeMy WebLinkAboutLot 42
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
M~ of property, owner
Le~a] des cl~ipt io~.~_
Numt>~x~ off ~drooms in house
(Fill out in
· of person requesting approval
Depth_
c. Casing Size
Distance from well to closest existing or proposed:
1, Sewer line
2, Septic tank
~. Cesspool.'...
5, Property Line
6. Other sources of possible contamination, i.e., creeks, lakes,
houses, barn~ drainage ditch, etc.
Sewage disposal system. -~ ~,
C, Name of septic tank manufactu~.~m ~~
1. If "home made" show diagram on re e side of this form.
d.' Disposal field or seepage pit tsize and type ~ . ' , ~/~/7
e, Percolation. Test ~esults
f; Percolation Test performed by ?' ~ ...... .
Use the reverse side of this form to show diagram. Diagra~ should include
~he foilowing information: p~operty lines~.well location, house location,
~ptlc tank location~ disposal area location, location of percolation test,
and direction of ground slope;
9. The i~foY~mtion on this form is true and correct tO the best of my knowledge.
S%gnature 'of Applicant
Date Signed
TO BE FILLED OUT BY HEALTH DEPART~.~ENT PERSONNEL
he above descra.bed sanitary facilities are hereby approved, subject to the
......... ~611owing cond~i'ions:
Conditions:
The above described sanitary facilities are disapproved for the following
reasons:
Approval is valid for one year following the date of approval.
CPJ: cw
- NOTE
?
-NOTE.-
DT1002419
Surveyor
PLAT O~
LOTS Z~A,'3-A, ^~o 14--A