HomeMy WebLinkAboutTURPIN BLK 2 LT 4
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REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILIRIE$
(Fill out in Triplicate)
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Name .of person requesting approval
Name of property owner /~ fA.e~,7'
Legal description ~ ~ ~>'~ ~
Number of bedrooms in house ~
Water Analysis:
a. Bacterial
b. DeterEent~
Well data:
b.
d.
Depth
Casing Size .....
Distance from well to closest existing or proposed:
2~ Septic tank, .?~-~
3~ Seepage Area
5. Property Line ~/Q. 3 --
6. Other sources of possible contamination, i.e., ereeks~ lakes~
houses~ barn, drainage dltch~ etc. ,%/~; C .
Sewage disposal system·
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Age of sys.tem._.
Name of septzs tank manufacturer
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
~Ouse foundation._ c7~"~ ,~
Percolation Test results
Percolation Test ~-~
Use the reverse side of this form to show diagram. Diagram should include
the following information: ~poperty llnes~.well location, house location,
septic tank location, disposal area location, location of percolation test,
and direction of ground slope.
The information on this form is true an(} cor/~%ct to the be%t of my knowledge,
: S~Eeture of Applicant~/ Dale Sign%d
TO BE FILLED OUT BY HEALTH DEPART~.~ENT PERSONNEL
The above described sanitary facilities are hereby approved, ~t~ject to the
~611owing cond~{ons:
The above described sanitary facilities are disspproved for the following
reasons:
Signal/of ~iei'~'-l... ~"' ,. , .', Dat~ .." .
Approval is valid for one year'following the date of approval.
CPJ:cw
\ '~ REQUesT FOR APPROVAL OF
~ ~%0...// INDIVIDUAL SEWAGE AND WATER FACILITIES
~ (Fill out in Triplicate)
1.
Number of bedrooms in house
7e
Water Analysis:
a. Bacterial
b. Detergent
Well data:
b.
e.
d.
Casing Size ,~ ! ~..
Distance from well to closest existing or proposed:
Cesspool
6. Other sources of p. ossible, contamination., i.e., creeks, lakes,
houses, barn, drainage dlteh, etc.. ~~ .
Sewage disposal system.
a. Age of syszem
b. Septic tank capacity in gallons
1. If "home made" show diagmam on Pevepse side o~ms-~' fomm.
d. Disposal field-o~ seepage pit size and type.
Distance to property line
to house foundation ~.
Use the reverse side of this form to show diagram. Diagram should include
the following information: ~ope?~.y ltnes~ .well location, house location,
septic Tank location, disposal area location, location of percolation test,
and direction of ground slope.
The informat, ion on this form is ~rue andOcor~ect to the best of my knowledge.
- ' ' ' ''Da~ Signed t '
TO BE FILLED OUT BY HEALTH DEPARTMENT PERSONNEL
The above described sanitary facilities are hereby approved, subject to the
Conditions: ....
asonOVedescribed sanitary facilities are disapproved
for
the
follbwing
sD --/¢~ r
Approval z~" valid for one ~ear following the date of approval.
CPJ:cw