HomeMy WebLinkAboutSOUTHWOOD PARK #1 BLK 5 LT 24/32 --2.-/- 000
a. Bacterial
b. Detergent .
b. Dept~ ....
c. Casing Size
d, Distance from well to closest eEisting or proposed:
1. Sewer line . ~
2. Septic tank . ,, . ~
3. Seepage Area. ~'
~. Cesspool~_ ._
5. Property Line
houses, barn, drainage ditch, etc.
Other sources of possible contamination, i.e., creeks~ lakes,
Sewage disposal system·
a. ^ge of ~ystem / 2~f~ .
b. Septic t k ' //
an capacity in gallons
Name of septic tank manufactumer
1. If "home made" show diagram on reverse side of this form.
Disposal field or seepage pit size and type .....
1. Distance to property-~line. '~ to- ~se foundation
e. Pefco] m%io~ Te~t k~esults
f. Percolation Test pemformed by
Use the reverse .side of this form to show dlaEram. Diagram shou inc
~_he following information: ~operty lines;.well location, house location,
l~p~ic tank location, disposa~ area location~ location of percolation test,
a~.., direction of ground slope.
The lnfor~ation on this form is true and correct to the best of my knowledge.
'$i~at'u~e ~f Appllca6t
Szgned
TO BE FILLED OUT BY HEALTH DEPARTMENT PERSONNEL
~e above described sanitary facilities are hereby approved, subject to the
'"~---'~&'ll~owing conditions i ....
The above descmibed sanitary facilities are disapproved for the following
r~ asoR8:
.~.'--.Ap~/a~cPJ~cw1, ~s valid for one year followzng the clare of ~;~oval,[j
21'
3.
5.
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate)
~ame .of person requesting approval ~ /l ~ft7
~a~ of property~owner ~ ~
L~gal..de~.criptio~ , ~]~ ~- ~zw/
Number:.o~ bedrooms in house ~ ,
Water.Analysis:
a, Bacterial
b, Detergent "" ' I/~
Well data: 2~ ~)~ ~ /~~a , Type
b, Depth
Casing Size
Distance from well to closest existing or proposed:
1. Sewer llne
2. Septic tank .
3, Seepage Area
5.
6.
houses, barn, drainage ditch, etc.
Sewage disposal system.
a. Age of system /0 ~d
b.' Septic tank capacity in gallons
c. Name of septic tank'manufactu~.~
Cesspool~ .~
Property Line
Other sources of possible contamination, i~e.~ creeks, lakes,
1, If "home made" show diagram on reverse side of this form,
Disposal field or seepage pit size and type .
1. Distance to property line
.to house foundation
h
e. Percolation~
Test
f. Percolation Test performed by. .
Use the reverse,side of this form to show diagram. Diagram should include
"~he foil,~ing information: p~operty lines~:well location, house location,
'~:Jc tank location, disposal area location~ location of percolation test,
a~ direction of ground slope.
The~.,-£~ o~,,r~'.~,on on this form is true and cor~ct t~ the best of my knowledge.
S%gnatu~ of Applicant / Date Signed
'TO BE FILLED OUT BY HEALTH DEPART~.~ENT PERSONNEL
' ~T'he above described sanitary facilities are hereby approved, su~.ject to the
roi!owing con~fons:
Conditions: ,~.~ .
The above described sanitary facilities are disapproved for the following
reasons:
'~Sig i ....
.,' "~' ~. "' . ' ." .[ 'D&te' '~','
Approval is valid for one year following the date of approval.
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