HomeMy WebLinkAboutTURPIN BLK 2 LT 22#
/'7
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate)
~-~,~. a~ .of person r~questing ap~.pval , ~ ~
2
5. ~Water. Analy~is:
a. B~c~i~
b. Detergent,
6. We~ data:
b. Depth
c. Casing Size
Distance from well to closest existing or proposed;
1. Sewer line
2. Septic tank ,,~',
3. Seepage Area ~ ....
Cesspool'
5. Property Line
6, Other sources of possible contamznatlon, 1,e., creeks, lakes,
houses~ barn, drainage ditch, etc.
Sew~ d~posal system,
c, Name of septic tank manufact~e~
l. If "home made" show diagram on reverse side of this form.
Disposal field or seepage pit size and type
1, Dist_anee to proper~cy-.3_ine /~)/ to house foundation
e, Pe~¢oJ~tio~ Te~t~nesults
f. Percolation Test performed by
U
se the re~ers~ .side o~ this form to show dlafram. Diagram should include
.... ~he foilowlng znformatlon: p~operty lines;.w~ll location, house locatzon,
~p~ic tank location, disposal area location, location of pemcolation tes~,
a~. direction of ground slope.
9,
The ~afor~a~ion .on this form is true and correc~ to the best of my knowledge.
Signature of Applzcant
TO BE FILLED OUT BY HEALTH DEPART~,~ENT PERSONNEL
Date Sz~ned
~e above described sanitary facilities are hereby approved, subject to the
.......... ~l~owinF con~ions:
Conditions:
The above described sanitary facilities are disapproved
reasons:
for the following
Approval is valid for one year following the date of approval.
CPJ: cw