HomeMy WebLinkAboutBURLWOOD TERRACE Block 3 Lot 5
REQUEST FOR APPROVAL OF
INUIVIDUAL SEWAGE AND WATER FACILITIES
Name .of person requesting approval_
%Ian~. of proper~y~ owner
Numb~. ~{ b~dr. ooms in house
Analysis:
Dete~ent " .
6, W~ll data:
Dis~nce fr. om well to c osest existing or
2. Septic ~an~_ = .... ,
3. Seepage Ar.aa .
Cesspool'
5. Property Line
5.
Other sources of possible contamination, i.e., creeks, lakes,
houses, barn, drainage ditch, etc.
Sewag~ disposal system.
a. Age of system .
b. Septic tank capacity in gallons
c. Name of septic tank manufactu~me~
1.
If "home made" show diagram on reverse side of this form.
d.' Disposal field or seepage pit size and type
1. Distance to propert~3 llne
to house foundation
f. Percolation Test performed by ......... ·
'"'~- Use the reverse ,side of this form to show diagram. Diagram should include
'.[-the following information: property lines~ .well location, house location,
m%~tic tank location, disposal area location, location of percolation test.
a~d direction of ground slope.
9. The }n-f,;,~n+~on on this form is true and correct to the best of my knowledge.
Signature '~'~ A~pl'[c~t - ~ate Sial'ed
~0 BE FILLE~ OUT BY HEALTH DEPARTHENT PEPSONNEL
The above described sanitary facilities are hereby approved, subje.ct to the
'~6'llowing cond,i'~ions: ' '
Conditions:
The above described sanitary facilities are disapproved for the followinK
'L"'~ as OT,. S: -
Approval is valid for one year following the date of approval.
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