HomeMy WebLinkAboutT13N R3W SEC 13 Lot 1 Tract 28P,
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(Fill out in TriplicateJ
l~ame .of person requesting approval
~m~ 6f property owner . ~~ ~ .....
Well data:
c. Casing Size .
d. Distance from well to closest existinE
6. Other sources of possible contamJnation~ i.e.
houses~ baPn~ ralnage ditch, etc.
Sewage disposal system.
a. Age of system ~,
b. Septic tank capacity in gallons
c. Name of septic tank manufacturer
1.
If "home made" show diagram on meverse side of this form.
d.' Disposal field or seepage pit size and type
1. Distance to property line to house foundation
e, P er col~tt ionx Test ~ s~ts
f. Percolation Test performed by .
Use the reverse side of this form to show diagram. Diagra~ should include
~the foilowing information: p~operty lines~.well location, house locatlon~
e~utlc tank location, disposal area location, location of percolation test,
a~.~ direction of ground slope.
The lr~fo~tlon on this form is true and correct to the best of my knowledge.
L~z~t~re-6f lpplic~n~ ~ Date Signed
T.~O BE FILLED OUT BY HEALTH DEPART~ENT PERSONNEL
~T~e above described sanit=r tlities are hereby approved, subje, ct to the
The
above
described
sanitary facilities a~e disapproved for the followin~
reasons:
Signat~fre of ~ffi¢i:Af.~ '?"' .~:i ' :. 'Date/:' ~ /
Approval is valid for one year following the date of approval.
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