HomeMy WebLinkAboutT13N R3W SEC 13 Lot 41LoT
.... ' REQUEST F~OR~APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILIT~
(Fill out in Triplicate)
5. .Wate~y~ is:
a. B act~-~ial
b. Detergent
-'"-'- 6~ We2_l data:
c. Casing Size
d. Distance from well to closest existing or proposed:
1. Sewer line
2. Septic tank
3. Seepage Area
~. Cesspool~_
5.
Pro~ePt~ _~ne,,u ~ ~{ , .
6.
Other sources of possible contamination, i,e., creeks, lakes,
houses, barn~ drainage ditch, etc.
Sew~ disposal system.
a. Age of system /¢~0 7.
b. Septic tank capacity in gallons / Z~ ~~
c, Name of septic tank manufactu~e~(~¢~¢~z~3 ~
1. If "home made" show diagram on reverse side of this form.
d.' Disposal field or seepage pit size and typ~
1, D nee to p~pe~y. 3_ine house fo~dation ~
e. Pe~colatior. Te~-t ~eesul~$
f. Percolation Test performed by , , , ._ _,
Use the reverse.side of this form to show dia£ram, Dia~ra~ should include
~..~-~he following, information: p~opePty linss;,well loeation, houss locatlon~
t~rtic tank location, disposal area location, location of percolation test,
a~...direction of ground slope.
The l~fox~ation on this form is tmue and comrect To the best of my knowledge.
SiKnature 'of Applicanz
Date Signed
TO BE FILLED OUT BY HEALTH DEPART~ENT PERSONNEL
he above described sanitary facilities are hereby approved, ,s,u~jecr t9 the
......... ~l~owin~ cond~o~s:
Conditions:
The above described sanitary facilities are disapproved
for the following
CPJ: cw