HomeMy WebLinkAboutSTEWART Block 2 Lots 1, 2 & 3
2,
3,
5,
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in T~iplicate) ~ 7g- ~7F~
Name .of person requesting approval
Y
Wate~ Anal~is:
a. Bacterial
b. Detemgent
Well data:
a.
c. Casin~ Size
d. Distance from well to closest existing or proposed:
1. S~er line_..3'f /-~.
2. Septic tank
3. Seepage Area
5. P~ope~ty Line ~ I
6. Other sources of possible contamination, i.e., creeks, lakes,
houses~ barn, dmainage ditch, etc. ~u~
7. Sewage disposal system.
a. Age of system ~7~ ..
b. Septic tank capacity in gallons
c. Name of septic tank manufacturer
1. If "home made" show diagram on reverse side of this form.
Disposal field om seepage pit size and type , ....
1. Distance to property line to house f~undation ,
· e, Percolatlor~.Test~esults ~ ...
f. Percolation Test performed by .
Use the reverse .side of this form to show diasPam, Diagram should include
.-~he foilowing infor~atlon: ~operty lines~.well location~ house location,
~ptlc tank location, disposal area location, location of percolation test,
~ direction of ground slope.
The l~for.w~.tion on this fo.~m is true and co~yect to the best of my knowledge,
Signature o~ Applicant ~ Date 'Signed
\.
T.~O BE FILLED OUT BY HEALTH DEPART~.~ENT PERSONNEL
~T~e above described sanitary facilities ape hereby approved, subject to the
......... ~611owin2 conditions: 3 ~-
Conditions:
The above described sanitary facilities are disapproved for the following
Approval is valid for one yea~ following the date of approval,
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