HomeMy WebLinkAboutLAMPERT BLK 1 LT 14A
INDIVIDUAL SEWAGE AND ~',ATER FACILITIES
~ame of property, owner
NlJm'£+~z, ~,f~ )>odrooms in house
Water, Analysis:
(Fill out in Triplicate)
~ ~'~..fL%.~ b. Detergent
6. Well data:
a. ~ ' ~
b. Depth ~,~-.~ ~ .~
Casing Size
Distance from well to closest existing or proposed:
1. Sewer line
3,
4,
5.
6.
Septic tank
Seepage Area
Cesspool'
Property Line
Other sources of possible contamination, i.e.~ creeks, lakes,
houses, barn, drainage ditch, etc.
Sewage disposal system.
a. Age of system
b.
C,
Septic tank capacity in gallons
Name of septic tank manufactu2~r
1. If "home made" show diagram on reverse side of this form.
Disposal field or seepage pit size and type
Distance to property line__ , to house foundation .
e., Parco ] at i¢)n~ Test 're gui ts
f. Percolation Test performed by
Use the reverse side of this form to show diaFram, Diagram should include
the fo] ].owing information: property lines;.we, ll location, house locatlon,
~'~!.,t{c tank location, disposal area location, location of percolation test,
a~,d direction of ground slope.
The i~f~r~r.a~on on this form is true and correct to the best of my knowledge,
Signsture of Applicant
TO BE ['If, LED OUT BY HEALTH I)EPART~.!ENT PERSONNEL
The above described sanitary facilities are hereby approved, subject to the
2ollo.w~.ng cond~.~'ions:
Conditions:
The
above
described
san~ar~* - facilities are disappr, oved for the following
reasons:
'~ignature of Df~i'ef~.~: ?.-'~--[z~7[... Date-~:'
;~.f~ :'~...,~ ..........
Approval is valid for one year following the date of approval,
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