HomeMy WebLinkAboutTURNAGAIN PARK #2 Block 2 Lot 4 No Longer Exists
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate)
Name of person requesting approval _~0~1~ /~ , ~ V3
Name of property owner_~, 4. ~3 ~--~/A ~
Legal description ~ 4d7 ~ ~(DC/ 2
Number of Bedrooms in house
Water Analysis:
B ·
b. Detergent~
Well data:
a. Type~.
B. epth 9 r
c. Casing Size ~ /~/¢ ~
d. Distance from Well ~o closes~ existinE or proposed:
1. Sewer llne
2. Septic tank__'3 o o
3. Seepage Area
Cesspool, ~ 0
$.Property Line ~ 0
6. Other s~uroes of possible contaminatlon~ i.e.~ Creeks~
houses, barn~ dmalnage ditch, etc.__ ~4/O/J~ lakes,
Sewage disposal system.
a. Age of system__~ V~AF,,J'
b. Septic rank capacity in gallons_~_~-~d
c. Name of septic ~ank manufacturer ~¢~/~
1. If "home made" show diagram on PeVers~ side of this foDm.
1.
Distance to property lzne ' ~_~_._._r° house foundatlon__~ 0 , .
e, Pemcolation Test ~esults~ z,6 F
f' Percolation Test Performed by ~_______~ ~~~ - ·
Use the meverse Si~e of this form to show dia~am. Diagram sh
the following information: . ould include
' p~operty lines~.well location, house location,
septic tank location, disposal area location location of percolation test,
and direct~L of ground slope. '
The information on this form is true and ~Orrecr ~o the best of my knowledge.
FILLED O~T --
TO BE BY HEALT_ H DEPART~,~ENT_ PERSONNEL
The above described sanitary facilities
~6'llowing con~f~ons! are hereby approved, subject _to the
Conditions:
Approval is valid for one year following the date of approval.
CPJ:aw
The above described sanitary facillt~as are disapproved for the following
reasons:
/0.. --