HomeMy WebLinkAboutDALE BRIGGS BLK 1 LT 25ADale Briggs
Block 1
Lot 25A
#050-181-28
REQUEST FOR. APPROVAL OF
' r �' INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in T li te)
J:
�. lla"s; of person requesting approval
�/yv-6 2. "Al -1 nu•, of prop<arty, owner
3. :r,yal •t�scri.prinn� '047
4, tlumLva of Tedrooms10 in house
[i? S. Water. Analysis -
a, Bacterial.
b. Detergent
6, well data:
�:OOF
a. Typo
b. Lepth
c. Casing Size
d, Distance from well to closest existing or propos d:
1. Sewer line
2. Septic tank-
3.
ank3, Seepage Area_,
4, Cesspool,
S. Property Line
6. Other sources of possible contamination, i.e., creeks, lakes,
houses, barn, drainage ditch, etc.
7. Sewage disposal system.
a. Age of system„
b. Septic tank capacity in gallons / S ne-_'j
c. Name of septic tank manufacturer Eip /
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
e: Percolation Test 'results
f. Percolation Test performed by
Use the reverse.side of this form to show diagram. Diagram should include
-{he following information: property lines; -well location, house location,
septic tank location, disposal area location, location of percolation test,
and direction of pround slope.
i
9. The information on this form Is true and correct to�the
ebbest of my knowledge.
signature opppliclKt Date Signed
TO BE FILLED Our BY HEALTH DFPARVIENT PERSONNEL
M-�e above described sanitary facilities are hereby approved, subject to the
fEllowinr conditions:
Conditions:
0
The above described sanitary facilities are disapproved for the following
reasons:
Signature ot MP3.cial-j . Date . j lyrt..
Approval is valid for one year following the date of approval.
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