HomeMy WebLinkAboutWENTWORTH BLK 4 LT 5LoT
Block;
%¸.
VA
REQUEST FOR APPROVAL OF
INDIVIDUAL SENAGE AND WATER FACILITIES
(Fill out in Triplicate)
~a~ of person requesting approval, , ,, M~. Ed, die Wilson,
2. · ~ o£ property~owner ~MR ~r. Valentine
3. [~aR. degcrj, pt~oq Lot 5~ Blk. 4~ Wentworth Subd.
4. Numb~"o~b~drooms in house
S. Water~ Ansl~is:
(~301 Piper, St.!
a. Bactemia]~ O.K.
b. Detergent ....
Well data:
a. Type_ Drilled .
b. Depth~
c. Casing Size
d. Distance from well to closest existing or proposed:
1. Sewer line
2. Septic tank_ 80 ft.
3. Seepage Area 105 ft,
4. Cesspool'
5. Property Line
6. Other sources of possible contamination, i.e., creeks, lakes,
houses, barn~ teenage ditch, etc.
d '
7. Sewage disposal system.
a. Age of system,,,
b. Septic tank capacity in gallons
850
Name of septic tank manufact~m~r
1. If "home made" show diagram on reverse side of this form.
Disposal field or seepage pit size and type.,,
1. Distance to property line
to house foundation
e, ?er¢olatlc~n~ Temt ~resul~s
f, Percolation Test performed by
-.
"-.o~. Use the reverse .side of this form to show diagram, Diagram should include
[['-~he foil.owing information: p~operty tines~.well location, house location,
m~I~tJc tank location~ disposal area location, location of percolation test,
an~ direction of ground slope.
9. The ~-£o~tlon on this form is true and correct to the best of my knowledge,
'S~gnatu~e 'of Applicant
Date Signe~
TO BE FILLED OUT BY HEALTH DEPARTMENT PERSONNEl,
~e above described sanitary facilities are hereby approved, ~u~ject to, the
......... ~!owing con~onsi
Conditions: None
The above described sanitary, facilities are disapproved for the following
~asons:
~'~<~.i, ' .,f7 .,., t October 23, 1968
' S~gh:~'t'u~'of ~ .... ~ate ~' .~;~, ,.~ ~
. D~vid Ha~qe~, ~a~i'tari~b' , , ~ ~'
'- ~pprova± zs vall~ ro~ one year fbi~owlhg the date of approval,
CPJ~ow
VA
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate)
· of person requesting approval M~ Eddie ~ltl~on
2. {~a~,~ o~ p~operty~owner ~'~R M~. Vale~ti~e
Numbur'of_be~lmooms in house
5. ~ate~Analy~is:
Ffp? st.)
b. Detergent
OoK~
Well data:
a. Typ. Dmilled
b. Depth__
c. Casing Size
de
Distance from well to closest existing or proposed:
1. Sewer llne
2. Septic tank 80 f~
3. Seepage Ar, ea.,!Q~..f~o
4. Cesspool'
5. Property Line
6. Other sources of possible contamination, i.e.~ creeks, lakes,
houses, barn, drainage ditch, etc.
Sewage disposal system.
a. Age of system
b. Septic tank capacity in gallons 8~0
c. Name of septic tank manufactu~.r
1. If "home made" show diagram on reverse side of this form.
d.' Disposal field or seepage pit size and type
1. Distance to property line
to house fo.undation
· e, Percolatlo~k, Test '~e su]_t s
f. Percolation Test performed by
Use the reverse ,side of this form to show diagram. Diagram should include
i~he foJ,~Jowing infoPmatlon: ~operty lines;.well location, house location,
~t~c tank location, disposal area location, location of percolation test,
an~ direction of ground slope.
9. The ~ox~tlon on this form is true and correct to the best of my knowledge.
\ S~gnature of Applicant Date Szgned
~O BE FILLED OUT BY HEALTH DEPART~4ENT PERSONNEL
~T~e above described sanitary facilities are hereby approved, subject to the
......... ~'l%owiny cond,~ons i
Conditions: None
The above described sanitary facilities are disapproved for the following
· O~obe~ 23, 1968
Signature Of ~f~a:EaA.~I z".'::2' [i " 'Date z~" .~? :'~;3.
- David Ha~kness, Sa~t~a~ian
- Approval &s valid for one year following the date of approval.
~ CPJ:cw
REQUEgT~ FOR, APPROVAL OF
SEWAGE AND WATER FACILITIES
(Fmll out in Tripl~c~t~
%~ lIa~ '°f pers°~ requestlng~approvat , ~ ~;~~~ ]
5. Water, Analysis:
b. Detergent '~1/'" '
Well data:
e. Casing Size
Distance from well to closest existing op proposed:
1. Sewer line
2. Septic tank
3. Seepage Area
Cesspool'_
Sewage disposal system.
5. Property Line
6. Other sources of possible contamination, i.e., creeks, lakes,
houses~ barn, drainage ditch~ etc.,
Septic tank capacity in gallons ff~, ~fl/~'/~t.
Name of septic tank manufaetu~e.~_
1. If "home made" show diagram on reverse ~ide of this form.
a. Age of system ..
Disposal field op seepage pit size and type,,
1. 'Distance to property line_ to house fmmdation
e. PereolatlonxT~st ~esults
f. Percolation Test performed by
Use the reverse .side of this form to show diagram. Diagram should include
The foilo%~ing information: p~operty lines~,well location, house location,
~tic tank locatlon~ disposal area location~ location of percolation test,
~ direction of ground slope.
Th~ h~fo~-~r~tion on this form is true and correct to the best of m~y~nowledge.
S~nat~re Of A~cant
T__O BE FILLED OUT BY HEALTH DEPART!,~ENT PERSONNEL
The above escrlbed sanitary f ' '
d '
.......... ~..- . acil~tzes are hereby approved, subject to the
following con~ons:
Conditions:
The above described sanitary facilities are disapproved for the following
reasons:
"Signature Of
..... ' '' '~' ~te ~" .p~,':'~.;.].
Approval is valid for one year following the date of approval,
CPJ:cw
VA
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate~)
t~a~e .of person requesting approval MY, Wtl~on
2.'' ~ame of proper~y~ owner. i , ,
3. Legal, descriptloq ,, Lot 51 Block ~t Wentwo~h Subd.
Number o~bedrooms in house
~ate~. Anals~is:
a. Bacterial
b. Detergent
We]_l data:
b.
Co
d.
Type Drilled ~ , i'
Depth. 90 f~.
Casing Size
Distance from well to closest existing or proposed:
1. Sewer line
Septic tank 70 f~,
3. Seepage Area 105 ft,.
Cesspool'
5. Property Line
6. Other souroes of possible contamination~ i.e.~ creeks~ lakes~
houses~ barn~ dmalnage dltch~ etc
7. Sewage disposal system.
a. Age of system
b. Septic tank capacity in gallons
c. Name of septic tank manufacturer
500
1. If "home made" show diagram on reverse side of this form.
d.' Disposal field or seepage pit size and type
1. Distance to property line to house foundation
~. Percolatic~% Test ~esults
f. Percolation Test performed by
Use the reverse .side of this form to show diagram. Diagram should include
'~the foJ]~owing information: p~operty lines~.well location, house location,
~-!-~c tank location, disposal area location, location of percolation test,
a~ direction of ground slope.
The 1-n~o~.,~+{on on tkis form is true and correct to the best of my knowledge.
Signature of ApPlicant .... Date Signed
T_pO BE F~ILLED ouT BY HEALTH DEPARTHENT PERSONNEL
The above described sanitary facilities are hereby approved, subject to the
.......... ~llowing cond~f~ons:
Conditions: N~e (Sewe~ li~e will be available by Novembem, 1969)
The above described sanitaryfaczlztzes' ' ' are disapproved for the following
Septembem 27~ 1968
'Signature of ~f~i~i~ ::v'~:-'?'~"
........ Date -~"
David Hamkness,
Approval is valid for one year following the date of approval.
CPJ:cw