HomeMy WebLinkAboutBIRCHWOOD PARK Block B Lot 4
INDIVIDUAL oEWAGE.AND WATER FACILITIES
(Fill out ~n Triplicate)
. Detemlent
data:
d. Distance from well to closest existing or proposed:
2. Septic tank__ '"" ......' k
3. Seepage Area '--',i' ' ) .
t '"' /
5. Property Line _'
6. Other sources of possible/contamlnmtion, i.e., creeks, lakes,
houses, barn, drainage ditch, etc.
Sewage disposal system.
a.
b.
c.
Age of system _ .
Septic tank capacity in gallor~s
Name of septic tank manufsctu~.r
1. If "home made" show diagram on reverse Side of this form.
Disposal field or seepage pit size and type_ .
1, Distance to pmoperty llne to house faundation
e, Perco]atlon. Test'I.esults
f. Percolation Test performed
Use the reverse .side of this form to show diagram. Diagram should include
'~'%he foil.owing information: p?operty lines~ .well location, house location,
~-!,t~c tank location, disposal area location~ location of percolation test,
a~4 d~.ection of ground slope.
The ~'~,,',~on on -this form is true and correct to the best of my knowledge.
'~'iFnature of Appli'ca~t "
Date signed
FILLED OUT BY HEALTH DEPART~.~ENT PERSONNEL
'£he above described sanitaryfacil~tzes' ' are hereby approved subject to the
follow,n? conditions: ......
Conditions: ~
The above described sanitary facilities are disapproved for the following
reasons:
Apt~roval is[/valid for one year following, the date of approval,
CPJ: cw