HomeMy WebLinkAboutLot 26
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
2.
3.
5.
1, ame o'f person requesting approval
Na~ of property owner
Legal. description
Numbex,
'oK bedrooms in house ./
Water Analysis:
a. Bacterial
b. Detergent ""
Well data:
a. Type
b. Depth
c. Casing Size
Distance from well to closest existing or proposed:
/
2. Ssptlc tank //0
4. Cesspool'
Property Line ~l .
6. Other sources of possible contamination, i.e., creeks, lakes,
houses~ barn, drainage ditch, etc.
Sewage disposal system.
a. Age of system
b. Septic tank capacity in gallons
c. Name of septic tank manufactu~e.r
1. If "home made" show diagram on reverse side of this form.
d.' Disposal field or seepage pit size and type , [0 X /~) ~r~-~.
1. Distance to property line to house foundation
e, Percol~t ionx Test ~eaults
f. Percolation Test performed by
Use the reverse side of this form to show diagram. Diagram should include
the foilowing information: ppoperty lines~.well location, house location,
n,~ptic tank location, disposal area location~ location of percolation test~
~ direction of ground slope.
The t~for.~tlon On this form is true and correct to the best of my knowledge.
!.. · . ,
r ' Date Si~ned "
~_0 BE FILLED OUT BY HEALTH DEPART~.~ENT PERSONNEL
/~he above described sanitary facilities are hereby approved~ subject to the
following cond~'ions:
Conditions: /~_
The above described sanitary facilities are disapproved for the following
reasons:
'S~znsture'~. of ~f~¢~a~l,:," :":'~ .i; ~:'' "'~'-.' :.' 'Date ;~i' ; ~'¢(~ !'~ ;:,L~
" Appmoval is valid for one year following the date of approval.
CPJ: cw
~...., , u~0 1 5 1978
~ ./' Telephone 26,4-4720
h;c~b ~ST., ...... . u , ~-,,. ~,O .,.rkl., OF INDIViDUAl. W.A'i'ER AND SE { I
4537 G~u~an A~s, Ekstrand~s work # 272-1466
~( ~ ~ ~ ::~(,~ t5<~2~ ........................................................................
PO box 1120 ~ch.~ ~ 99510
S ~ of Lot 26, Section 33, T13N, R3W, S.M.
[~] One I~] Four L-J Oti~er ...... ;
.... GI_E [ ,~,,/it 1_, F~] Two ,~-3 Five
'--!_1 ,~,, ~ , .-, n. L::-' i:AMi LY [~1. Three L~J Six
~ INDIVIDUAL* 70t dee~ ~'ATTACH WELL LOG. A well log is required for aH welk: dril:ed
t iNDIVIDUAt./ON-SITE~' ' ........
~ PUBLIC ~"'' ' - .-
NC'TE:'FI4EINo,*.:,..I:.)NFEEfuL,~T.-,Cc,_. i:AN"/EACI!R:tQUESI[B,c:')]EFfOCE,~$ L: CAN DE INITI.~',~TED.
, E. O[: !/E,~;IDEI',JCE NLIM~,ER OF BEDHOOM8
[~'i SINGI.E FAMILY
[~] MU! '1 IIH.E FAMILY
2, '~r~;/tt'i'l!;R 3LIPPLY
INDIVIDUAL
COMMUNITY
PUULIC IJ71LITY
Ccmneclion Verified
.... wkt .. DISPOSAL SYSTEM
[:.]Sc~Dtiu ~ ank or - ' '
L Ho lng fa~k
i Siz(~: ............. If Tnnk is homemad[~
I ........... ..........
ONE [~1 THREE [-] FIVE !T] OTHER
TWO lZ] FOUR L~ SIX
DATE DRILLED
LOG FIECEIVED
.---~I~AI'PROVED FOR . ___.~ .... BEE)ROOMS
[.] CONDI'ilONAL ,/'~1 r ll()VAL (hdlel mLISt accompally celti[icate)
i:L] DISAPPilDVEI')