HomeMy WebLinkAboutT13N R3W SEC 13 S2 Lot 3
· APPLI¢%NT FILLS OUT UPPER HA~ ONLY
Phone
Buyer
Address ? Zip Code
Lending Institution Phone
Realty Co. & A~nt Phone
Address Zip Code
Type of Resi~nce
~e Family
Water Sup ly
/ LOG. A w~[ is required for all wePs drilled since June 1975.
WELL
Icg
U Community ~ ' ~ For wells drilled prior to that date, give well depth (attach Icg if available).
~ Public Utility
li~ Utility When Connected to Public Utility: ~ ~ ,
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OOESSING CAN BE INITIA~EB.
Time Time Time Time
Date Date Date Date _'~ . - -
Inspector Inspector
Field N°tes: ~, ¥~t.~
ENVIRONMENTAl. PROTECTIO~
RECEIVFD
( ~'~PPROVED BEDROOMB *CONDITION80P APPROVAL
( ) DISAPPROVED
DATE ~-~//~_~3.
Well to Tank Septic Tank Size