HomeMy WebLinkAboutLot 01
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate)
~.,~ Name ,of person requesting approval ....... Mr,, Charles Reese
2. ~ame of property~owner ssme
3. h~y.al descriptio~ (g~24Ran~eview) Lot 1, ~lk ? Kluane Terrace~b~o . ....
4. Numbe~.~.o~ ~edrooms in house
5. Water, Analysis:
a. Bactemial
b. Detergent
Well data:
a. Type
b. Depth
c. Casing Size
d.
C. A. U.
Distance from well to closest existing or proposed:
1. Sewer line
2. Septic tank
3. Seepage Area
4. Cesspool'.,
5. Property Line
6. Other sources of possible contamination, i.e., creeks, lakes,
houses, barn, drainage ditch, etc.
Sewage disposal system.
a. Age of system
. C. Ao U.
b. Septic tank capacity in gallons .
c. Name of septic tank manufactu~e.r
1. If "home made" show diagram on reverse side of this form,
d.' Disposal field or seepage pit size and type
Distance to property line
to house foundation
Percolation. Test'~esults
f. Percolation Test performed by ,
Use the reverse.side of this form to show diagram. Diagram should include
.'~he foil.owing information: p~operty lines~.wetl location, house location,
~,!~-~ic tank location, disposal area location, location of percolation test,
a~ direction of ground slope.
The ]~-[o~.~mtlon on this form is true and correct to the best of my knowledge.
~ $,,ignature of AppliCant Date Signed'
\
TO BE FILLED OUT BY HEALTH DEPART~.~ENT PERSONNEL
'The above described sanitary facilities are hereby approved subject to the
roi%owing con~iOnS:
Conditions :_ none
The above described sanitary facilities are disapproved for the following
reasons:
Szgnatur~ of ~ ~ ..
Rolf Strickland, Sanitarian
Approval is valid for one year following the date of approval.
CPJ: cw
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate)
~ame .of person requesting approval
2. · ~ame of property~owner
3. heEal descriptio% , , .
4. Numbex~'o~ ~edrooms in house
5. Water, Analysis:
a. Bacteria~l
b. D~te,~ent
a. Type
b. Depth
c. Casing Size
Distance from well to closest existing or proposed:
1. Sewer line
2. Septic tank
3. Seepage Area
Cesspool'
5. Property Line
6. Other sources of possible contamination, i.e., creeks, lakes,
houses, barn, drainage ditch, etc.
a. Age of system ~.
b. Septic tank capacity in gallons
c. Name of septic tank manufactum~.r
1. If "home made" show diagram on reverse side of this form.
d.' Disposal field or seepage pit size and type
1. Distance to property line to house foundation·
Percalat ion~ To, st 'ce so_Its
f, Percolation Test performed by
Use the reverse,side of this form to show diagram. Diagram should include
'the foi].owlng information: property lines~,well location, house location,
~'>lm~c tank location, disposal area location, location of percolation test,
a~ ~ ·
drectlon of ground slope,
9. The i'n~,>~-~t{on on this form is true and correct to the best of my knowledge.
S~gnature of Applicant
Date Szgned
T~O _BE FILLED OUT BY HEALTH DEPARTMENT pErSONNEL
above described sanitary facilities are hereby approved, s.ubje, ct to the
The above described sanitary facilities are disapproved for the following
reasoner
Approval is valid for one year following the date of approval.
CPJ: cw