HomeMy WebLinkAboutBROOKWOOD BLK 2 LT 1
_ -~ . TelePhone. ~B4-4720 RECE!~V~ EDi '", .......
REQUEST FOR-APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS,' Compl ere all parts on page 1. In¢omplete requests wiil not be processed. Please allow ten (10).days for processing.
MAll. lNG ADDRESS
PFI'OPE~ RESIDENT ( f d fferent from above) .... PHONE
3. LENDING INSTJTUTtON .. - I PHONE
MAI LI'NG ADDRESS ·
- -~ ' - : ~ ' PHONE
a,~R EALTOR/AG ENT ,
MAILING ADDR ESS
N '
[] SINGLE FAMILY
~ LY
[] INDIVIDUAL* *ATTA well log is required for all wells drilled
[] COMMUNITY since Jane 1975. For wells drilled priOr to that date, give well
--~ F a ~ ~ PU,BLtC UTILITY · depth (attach log [f available.)
8. SEWAGE DISI~ALSYSTEM '
. [] INDIV DUAL ON SITE**/ ..... If nd vdual/on-ste, gve nsta atondate .
· __ If system is over two (2) years old an adequacy test is required
IJ~ PUBLIC UTIL TY - t' -e r'L
Dy nl$ IP pa ~:men;.
NOTE: TH E INSPECTION -FEEMUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN'SE INITIATED.
72~010{3/7'8)
[] One [] Other
[] Two [] Five
[] Six
TIME
DATE
INSPECTOR
THIS SIDE FOR OFFICIAL USE ONLY
INSPECTION APPOINTMENTS
TIME
DATE
INSPECTOR
DATE RECEIVED
TIME
DATE
t NSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE
[] SINGLE FAMILY
[] MULTIPLE FAMILY
2. WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTILITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON -SITE
[]PUBLIC UTILITY
Connection Verified
i--ISeptic Tank or [] Holding Tank
Size: If Tank is homemade
give dimensions:
[] ONE
[] TWO
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOl LS RATING
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
Septic/Holding Tank
NUMBER OF BEDROOMS
[] THREE [] FIVE
[] FOUR [] SiX
IAbsorption Area ]Sewer Line
[] OTHER
Nearest Lot Line
5. COMMENTS
DATE
LEGAL DESCRIPTION
~"'~APPROVED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
BY (Title) ~
72-010 (Rev. 3/78)