HomeMy WebLinkAboutSOUTHWOOD PARK BLK 2 LT 3
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate)
1.Ianm of person requestlng approval ,,~~
2.~' ~a~ Of property:owner ~_r~.~o_7 ~' i
6%
Numbex~-~o~ bedrooms in house
Watch Analysis: ~ ~ L~
a, Bacteria].
b. Detergent
Well data:
a, Type..
b, Depth.
c. Casing Size
d. Distance from well to closest existing or proposed:
1. Sewer line
3. Seepage Area
4, Cesspool'_
5, Property Line
6. Other sources of pos.sible contamination, i.e., creeks, lakes,
houses, barn, drainage ditch, etc.
Sewage disposal system,
a. Age of system I~.n/c_.e~
c, Name of septic tank manufactu~( . ~//'
~ /
1. If "ho~e made" show dlagpam o~ mevemse sade of this fo~~
Disposal field or seepage pit size and type , ,
1, Distance to property ltne ;-~ % house founda(io~ ~ t¢ ',¢ /-/-'
Percolatlo~,T~st '~e suO_t s
f. Percolation Test performed by
Use the reverse .side of this form to show diagram, Diagram should include
"~he foil.owing info~mation: ~.~operty lines~ .well location, house location,
~>~.m~{ c tank location, disposal area location, location of percolation test
aa~ d~rection of ground slope.
this form is~true~and correct-~o the best of m~-knowledge.
. .~ ~lic ,
T._O, ~E FILLED OUT BY HEALTH DEPARTMENT PERSONNEL
[~T~e above described sanitary facilities are hereby approved, subject to the
.......... ~l!owing con~iions: ""
Conditions:
The above described sanitamy facilities are disapproved for the following
Sign~e~ ~f~icf&~.¢ ~"/'L.,' J. · Da p ~ '
Approval is valid fo~ one yea~ following the date of approval.
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