HomeMy WebLinkAboutT13N R3W SEC 26 SE4 NE4
iNDIVIDUAL SEWAGE AND ~',ATER FACILITIES
' p rs on requesting approval
~ 0 5. Wate~ Anal)~sls
6. Well data:
Casln Size_
Distance from well to closest existing or proposed:
1. Sewer line
2. SeptJ c tan~
4. Cesspool'
?
5. Property Line
houses~ barn~ drainage ditch, etc.
Sewage disposal system.
Other sources of possible contamination~ i.e.~ creeks, lakes,
Age of system ( 0 ~<5, .
Septic tank capacity in gallons
1. If "home made" show dia~ra~ on reverse side this form.
Disposal field om seepage pit size and type,.
1. Distance to property line to house fo~dation
e, Percolatioa Test ~res~d~ts
f. Percolation Test performed by
Use the reverse .side of this form to show diagram.
Diagra~ should include
ยท '-~he foJ]~owing information: p?operty lines; .well location, house location,
~I~c tank location, disposal area location, location of percolation test,
and, direction of ground slope,
9. The ~'~r~+.~on on this form is true and correct to the best of my knowledge.
k. 'S~gnature 'of Applicant D~te SiOn'ed'
T_~O BE FILLED OUT BY HEALTH DEPART~-}ENT PERSONNEL
he above .escrmbed sanitary ac~l~t~es are hereby approved, subject to the
........ ~_~6'l!owing cond~iionsi ,,
The above described sanitary facilities are disspproved for the following
reasons t
- Approval is valid for one year following the date of approval.
CPJ:cw
