HomeMy WebLinkAboutTRANQUILLITY HEIGHTS Block 45 Lot 30
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate)
~ ~_ Name of person request~.ng approval ;',i,,~ < '~ ,
5. Nates. Analysis:
a ~ Bacterial ,
b, Detergent_ ._ : .
We~ data:
b, Deptk .... ~'~ .... .
c. Casing Size ,
Distance from well to closest existing or p~o~osed:
1, Sewer llne
2. septis tank., x .
3. Seepage AreaX~L.
~, Cesspool].. _~ .... ..
5, Property Line_~/__.
6. Other sources of possible contamination, i,e., creeks, lakes,
houses~ barn~ drainage ditch~ etc. ....
7. Sewage disposal system.
a, Age of system ] // ~7~,,, ,
b. Septic tank capacity in gallonS.,~f~P
c, Name of septic tafik manufacturer
1. If "home made" show diagrem on reverse side of this form.
Disposal, field or seepage pit size and type~.~./',~,;~J_~ :. 7:' ~.:__
1. Distance to proper~y, line. i~%)~'::? ' __tO house fo~dation__J ~ ~
a, Pereolatio~ Text h'esults
the reverse .side of this form to show diagram, Diagram should include
following ~nfo~mation: ~.~operty lines; .w~ll lc, catiOn, house locatton~
~{)Tic tank location, disposal area locatior~, locat%on of percolation tesT,
an~ direction of ground slope,
9, The l~lfor~%atlon on this form i.~; true and correct to the best of my knowledge.
3F BY HEALTH DLP^RT..~EN~ PEgSONNEt
~-%'he above described panitary facilities az~e hereby approved~ sub~__ect to t__he
~'ll. owin~ conflUX'ions ~ '
Conditions:
*The above described sanitary facilities are disapproved for the following
reasons:
Data ",' . ~, c~.~.~,
//. '
', App~'~v~l is valid fo~ one year followin~ the date of approval.
...- CPJ: cw