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HomeMy WebLinkAboutT15N R1W SEC 18 LT 61 (D 0 ~ 0 0 0 0 © ~4~ U 0 0 ~ 0 ,-4 HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM PART I.--TO BE COMPLETED BY FHA INSURING OFFICE MORTGAGOR (~i.~ ~.~J~ SUBDIVISION NAM~ JBLOCK NO. [LOT NO. TOTAL .U~.¥~.' ] ~JS~r~ ~ New installation ....17 WA]~- SUPPLY ~z Public system ~ Communi~ system SEWAGE DISPOSAL BY: J~J Public system ] Community system additional bedrooms? {If Yes, haw rnany?~ SYSTEM DESIGNED FOR g Individual .o. OF BDRMS* GARBAGe DESPO$AL ~ Individual PART II.--TO BE COMPLETED BY HEALTH DEPARTMENT HEALTH DEPARTMENT INSPECTOR'S SKETCH It is the opinion of the [] State [] County [] Local Department of Health that this individual water-supply system [] is [] is not satisfactory as a domestic water supply for the subject property. It is the opinion of the [] State [] County [] Local Department of Health that this individual sewage-disposal sys- tem with proper maintenance: J~J Can be expected to function satisfactorily, and [] Cannot be expected to function satisfactorily is not likely to create an insanitary condition DATE SIGNATURE REQUEST FOR APPROVAL OF INDIVIDUAL SEWAGE AND WATER FACILITIES (Fill out in Tmiplicate) l~amc of person requesting approval ~}~~ .,,~,,~1~~_ ~an~ of prope~ty~owner deacniptio~ Z 0 Numbex~,o~j~drooms in house. Water, Analysis: 'V '; . 'r4. , .... ~. D~stance f~om well to clos t existing o~ p~oposed: 1. 8ewe~ linc 2. Septic tank 3. Seepage Area _/~J. Well data: a. Type ~. Cesspool' ./.~. I 5. PPoperty Line. ~2/&9 ~ ~ 7. Sewage disposal system· 6. Other sources of possible contamination, i.e., creeks, lakes, d houses, barn, ralnage ditch, etc. ~ · ' y Septic tank capacity in gallons Name of septic tank manufacturer 1. ,:QO~, If "home made" show diagram on reverse side of this form. Disposal field om seepage pit size and type 1. Distance to proper~y line ~¢ to house foundation e, Percoiatlo~ Test results .......... · f. Percolation Test performed by ...... ' Use the reverse .side of this form to show diagram, Diagram should include ~he foil.owing information: p~operty lines;,well location, house location, ~i, Iqc tank location, disposal asea location, location of percolation test, a~ direction of ground slope. The l~,[,*r.,r~t~on on this form is true and correct to the best of my knowledge. ~ 'Signature of Applicant Date Signed ~0 BE FILLED OUT BY ~E,A,LTH DEPAET~4ENT PERSO,N,NE~ above described sanitary facilities are hereby ~pproved, subject to the .ro. llowzng condi~ona: Conditior~s: The above described sanitary facilities are disapproved for the following Signature 6f ~ffle~,~,' ' '" ' 'i '~t'e ~' " Approval is valid for one year following the date of approval. CPO:cw