HomeMy WebLinkAboutLAKESIDE TERRACE LT 3
REQUEST FOR APPROVAL OF
INDIVIDUAL SEW^GE AND WATER FACILITIES
(Fill out in Triplicate)
~~ Name ,of person requesting approval ~
2. x~ame of proper~y[ owner L L J,///~/g~£~ , ~''
Numbe~-o~.~bedrooms in house, , ~ ~ ....... . ~,
Mate~ 3lnalysis:
Bactemial.
Detergent
'~ 6~ We]] data:
b. Depth .
c. Casing Size
d. Distance from well to closest existing or proposed:
1. Sewer line
2. Septic tank .. ..
3. Seepage Amea
~, Cesspoot~,,
5. Property Line ....... ,
Other sources of possible contamination, i.e., creeks, lakes,
houses, barn, drainage ditch, etc.
7. Sewage disposal system.
a. Age of system
b. Septic tank capacity in gallons
c. Name of septic tank manufactu~m
1. If "home made" show diagram on reverse side of this form.
d.' Disposal field or seepage pit size and type ~'~1']~/~7~'~ ....
1. Distance to property~ line to house foundation .
-e, Perccbt~tio~ Te~t ~pesults
f. 'Percolation Test performed by
~ Use the reverse .side of this form to show diagram, Diagra~ should include
.~..~he following inforcnation: property lines; .will location, house location~
'~gtic tank ~ocation, disposa~ area location, location of percolation test,
a~.. direction of ground slope.
9. The ~for~atlon on this form is true and correct To the best of my knowledge.
'of Applica~%
TO BE FILLED OUT BY HEALTH DEPAET[.?ENT PERSONNEL
' ' D~te Signed
~T~e above described sanitary facilities are hereby approved, subject to the
.......... ~l~owing con~ionsi ~
The above described sanitary facilities are disapproved for the following
reasons:
. .-',_ .,:.,, 'q,;~ /Y/ ::' :
· ,P-'//.../.z . - -- / .' -'-/z · . ,,
"- App~val is valid for one year following the date of approval.
..- CPJ: cw
TOTAL NUMBER: Can attic or other area be made into
BASEMENT [] New installation additional bedrooms?
LIVING UNITS BEDROOMS BATHS (If Yes, how many~)
WATER SUPPLY BY: SYSTEM DESIGNED FOR
[] Public system [] Community system [] Individual NO. OF BDRMS. GARBAGE DISPOSAL
SEWAGE DISPOSAL BY.'
[] Public system [] Community system [] Individual [] Yes Fl No
PART fl.--TO BE COMPLETED BY HEALTH DEPARTMENT
HEALTH DEPARTMENT INSPECTOR'S SKETCH
......... Z_-ZZZZZ_-ZZ_-ZZZ_-ZZZZ_-Z~Z--ZZZ
.......... ........... i ~ :-: -- -:: :-: :------ -: ~ --- --- ~--- -: -----: -- ~ -:
.......... ZZZEZZZ ..................
........... ~'Z~_ZZZZZ-ZZZZZZZZZZZZZZZZZ
........... F~ '- ........ ZZ-ZZ_-ZZZZ_-ZZZ
It is the opinion of the r-] State [] County [] Local Department of Health that this individual water-supply system
[~is [] is not satisfactory as a domestic water supply for the subject property. PUBLIC W^TER
It is the opinion of the [] State [--] County [X[X[~ Local Department of Health that this individual sewage-disposal sys-
tem with proper maintenance:
[-~ Can be expected to function satisfactorily, and FI Cannot be expected to function satisfactorily
' is not likely to create an insanitary condition
July 30, 1970 Environmental Health Supervisor
NOTE: The heal/auth~ should complete the appropriate op' ' statement above and affix date, signature and title in the
spaces provided.
Use of the above grid for Health Department Inspector's sketch aR well as use of the back of this form is at the option of the
health authority.
PART Ill.--FOR USE OF FHA OFFICE
TO THE CHIEF UNDERWRITER;
I have reviewed the foregoing and the pertinent FHA Compliance Inspection Report, and recommend that 'the
Individual water-supply system be considered ~] Acceptable [-'] Not Acceptable
Sewage disposal be considered ~] Acceptable [] Not Acceptable.
DATE SIGNATURE J~ CHIEF ARCHITECT
] DEPUTY FOR CHIEF ARCHITECT
HEALTH AUTHORITY APPROVAL FHA.F?r~573
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¥'cte Ya~-~s ~%d~inistr~tio~
PoO. ~;o>; 1599
~ar Si rs:
{)n ~ay 21, 1970, po'~'$oinoi o£ this t)e?artm'ent insimcted tiio sower
and ~at~r f~ciiitios ibr thc subject housc.
G~nt~'at z%isska. Utilitios s~.~]?~ry sower iino is ~pproximatciy
7{)~ ~ro~ ~.h~. t:~gc i; lot. 'Ibis Departmont ~lr~nt~ temporary a?
pi'oval t,~ the pi~sent ~ewor system providii~g th~i~: f~rndi~ arc
Gi~cc roiy,