HomeMy WebLinkAboutBIRCHWOOD PARK BLK E LT 7A?
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5. Wa~er, AnalySis:
d. Disbnce fPo~ w~ ,o closest existinK oP ppopOsed,
1. Sewer line
2. Septic tank
3. Seepage Ar. ea
4. Cesspool'
5. Property Line
6. Other sources of possible contamination, i.e., creeks, lakes,x
houses, barn, drainage ditch, etc. , ,
.
a. Age of system
b. Septic tank capacity in gallons F
c. Name of septic tank manufactu~.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 proper~y line
to house foundation ..... .
Percolation~T~st"mesults
f. Percolation Test performed by
Use the reverse.side of this form to show diagram. Diagram should include
'~the fo[].ow~ng information: pFoperty lines~.well location, house location,
~'-'.v~c tank location, disposal area location, location of percolation test,
a~ ~ ·
d tee:lan of ground slope.
The ~"{'~,',~m on this form is true and correct to the best of my knowledge.
'~'~gnature 'o{ ' " ................
, Applicant '~'at e Signed
lp_BE FILLED OUT BY HEALTH DEPARTI.~ENT PERSO~E~
above described sanitary facilities are hereby ~pproved, subject to the
~6'l~owi__ng con~on~: ' '-"
Conditlon~ :_~
The abovedescribed' sanitary facilities are disapproved for the following
reasons:
Signal-ute' °f ~f[i'~i;&~ ~[ ~t' -~T~N~-~
App.-oval is valid for one year following the date of approval.
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