HomeMy WebLinkAboutWENTWORTH BLK 3 LT 4 P-386
2,
3.
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
m~ of person requesting approval
Number'o~..b~&rooms in house
a. Bacterial,
b. Detergent .~,/~/
b. Depth
?
Casing Size
Distance from well to closest existing or proposed:
1, Sewer line
2. Septic tank ~[ .
3. Seepage Area__~ /
4. Cesspool'
5. Property Line
houses, barn, drainage ditch, etc.
Other sources of p ss~ble contamlnation~ i.e., creeks, lakes,
Sewage disposal system.~, a. Age of system
b. Septic tank capacity in gallons
Name of septic tank manufacturer
1. If "home made" show diagram on reverse side of this form.
Disposal field or seepage pit size and type ~ ~
_ . ~.~ ~'~ ~, .... ~
· e, Percolatlo~,. Test '~esukts ,.
f. Percolation Test performed by
Use the reverse .side of this form to show diagram~ Diagram should include
X~ha fo]_].o~zng info~ation: ~.~operty lines~ .well location, house location,
~l~tdc tank location, disposal area location~ location of percolation test~
and direction of ground slope.
\
9. The ~T~fox~tion on this form is true and correct to the best of my knowledge.
\ 'S~gnature 'of Applicant Date Signed'
~0 BE FILLED OUT BY HEALTH DEPART~.~ENT PERSONNEL
~he above described sanitary facilities are hereby approved, subject to the
rollowzng ' ' '
· conditions:
Conditions
The above described sanitar~faczlztzes' ' ' are disapproved for the following
reasons:
Approval is valid for one year following the date of approval,
· CPJ:cw