HomeMy WebLinkAboutT13N R3W SEC 28 General Information
a. Bacte~eial
b. DetePgent
WelX data:
a. Type ~
c. Casin~ Size
Distance from well to closest existing or pmoposed:
1. Sewer llne
2. Septic tank /~/
3. Seepage Area,,,./~0 ! ~
4. Cesspool',.
5. P~opemty Line
6,
Othem soumces of possible contamination~ i,e., creeks, lakes,
houses, barn, drainaEe ditch, etc.
Sewage disposal system.
b. Septic tank capacity in gallons~~____~
c. Name of septic tank manufactu~e.m
1. If "home made" show dia~Pam on revemse side o~ this fomm.
d." Disposal field o~ seepaKe pit size and type
Distance to pmoperty line ~!to house foundatlon/~Z_,
· e, Percolatlom Test'~esults ..
f. Percolation Test performed by. ~ ... ,
Use the reverse .sid~ of this form to show diagram, Diagram should include
'-~he foil.owing infor~atlon: p~operty lines~.well location, house location,
~t.~c tank location, disposal area location, location of percolation test,
a~ d~mection of ground slope.
9. The ~-[o-r~t~on on this form is true and correct to the best of my knowledge.
S~hature of Applicant ~ate Signed
T~O BE FILLED OUT BY HEALTH DEPART~,~ENT PERSONNEL
~e above escrzbed sanitary facilities are hereby approved~ subject to the
d '
~l!owing conditions:
Conditions:
7
The above described sanitary facilities are disapproved for the following
"Approval is valid for one year following the date of approval.
CPJ: cw