HomeMy WebLinkAboutT12N R4W SEC 10 LT 14 E2
REQUEST FOR APPRO¥^L OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate)
21" Marne of proper~y~ownem
~yaJ~ des:crlptlo~
q. Number,o~ bedrooms in house
.of person requesting approval
C
. 5/V
5. Water~ Analysis:
a. Bacteri&l
b, DeterEent
Well data:
b. Depth.
c. Casing Size
d. Distance from well to closest existing or proposed:
1. Sewer llne
2. Septic tank
3. Seepage nre~
q. Cesspool',,,,
5. Property Line
houses, barn, drainage ditch, etc.
Other sources of possible contamination, i.e., creeks, lakes,
7, Sewage disposal system.
If "home made" show diagram on reverse side of this form.
a. Age of system i g'~O
b. Septic tank capacity in gallons
c. Name of septic tank manufacturer
1.
d.' Disposal field or seepage pit size and type
_ :t,,.x, :,xx
1. Distance to property line to house foundation
e, PercoiatiO~.Te'st ~esults .... .
f, 'Percolation Test performed by . ..~ ..... ,
Use the reverse .side of this form to show diagram. Diagram should include
'[-~he foi%owing information: p~operty lines~.well location, house location,
~!m~{c tank location, disposal area location, location of percolation test,
a~ direction of ground slope,
The lnfo~p,~tlon On this form is true and correct to the best of my knowledge.
S~gnature of Applicant
Date Signed
TO.~BE FILLED OUT BY HEALTH DEPART~.~ENT PERSONNEL
The above described sanitary facilities are disapproved for the following
reasons:
S'ign~/~re of ~f~i'~f~jl ~ '-=~:'5-~." ' ' ' Date "~'
Approval is valid for one y~ar following the date of approval.
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