HomeMy WebLinkAboutVANS Block 3 Lot 3 Subdivided to 3W and 3E
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND W~TER FACILITIES
(Fill out in T~iplicate)
Legal
description
umber of bedrooms
in house
Water Analys~s:
a. BacTerial
b. Detergent
Well data:
CaSing Size~
7. Sewage disposal system,
ZStance from Well to closest exiStinm
or
Proposed,
1. Sewer line/~g~
2. Septic tank ]~
3, Seepage Area~.
Cesspool.
5. Property Line ~_~_.~,
6. Other SOurces of POSsl~te ~n,~ami~atl~u, I.e., ~m, lakes,
houses, barn, drainag~
a. Age of
b. Septic tank capacity in gallons
de
Name of septic tank
D~spos~l riel4
1. Distance ta
f. Percolation Test performed by
USe the reverse side of this form to show diagram. Diagram should include
the following information: ~operty linss~.well location, house location~
septic tank location~ disposal area location, location of percolation test,
and direction of ground slgpe.
9. The information on this form is true and cormect to the best of my knowledge.
Szgnature Of Applicant Date Signed
TO___BE ,FI~,ED OUT, B~ HEALTH DEPART!.~ENT PERSONNEL
~The above described sanitary facilities are hereby approved, subject to the.
.......... ~61towing conditions:
Conditions:
The above described sanitary
reasons:
facilities are disapproved for the following
SignaTure of ~e~r~.~ '~ ,.~ '. Date ~'.
Approval is valid for one year following the date of approval.
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