HomeMy WebLinkAboutCAMPBELL HEIGHTS BLK 4 LT 12B'42. 0oo
Da~e SOILS LOG CASING LOG .
Total
Time Depth Materials and Ramarkt Length Length
_~,~c ~v~,lN.,t~) ' 3 3)-g .SUBSURFACE EXPLORATION
' ' Shift Repod of Operations
~o,.. & /~// p ~//
INSPECTOR
DAI E RECEIVED
INSPECTION
APPOINTMENTS
TIME TIME TIME
DATE /) DATE
,.S.ECTOR/3,~ ~ ,.S~C.O~ mS~C~O~
ItAY 1 1981
~NVI~ON~TAL SANITATIO~
~"'~'~ RECEIVED
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
~I~ECTIONS: Complete all par~ page 1, Incomplete r~u~ will aot~ pr~, ~ease allow ten 110) days for pr~sing.
I
STREET'OCAT,O. u /757-
TYPE OF RESIDENCE NUMBER OF~BEDROOM$
I'--I One [] Four [] Other~
[~ 'SINGLE FAMILY C"I Two [] Five
[] MULTIPLE FAMILY ~ Three [] Six ,
7. WATER SUPPLY
INDIVIDUAL*
COMMUNITY
[] PUSLIC UTILITY
· ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available,)
SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE**
1': PUBLIC UTILITY
,YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPJ.~~EST BEFORE PROCESSING CA:,N BE INITIATED.
72.o,o,... ~7,, . (,.~D ~ ~D ~ ~ ~ ~
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
[~] SINGLE FAMILY
[] MULTIPLE FAMILY
2. WATER SUPPLY
r-I INDIVIDUAL
[] COMMUNITY
~--I PUBLIC UTILITY
Connection Verified,
3. SEWAGE DISPOSAL SYSTEM
F-IINDIVIDUAL/ON -SITE
[]PUBLIC UTILITY
Connection Verified
[-ISeptic Tank or i--I Holding Tank
Size: If Tank is homemad~
ive dimensions:
NUMBER OF BEDROOMS
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
[] ONE [] THREE r-I FIVE
r"l TWO i--i FOUR [] SIX
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOILS RATING
TYPE OF TANK MANUPACTURER
TOTAL ABSORPTION AREA MATERIAL
Septic/Holding Tank
Absorption Area JSewer Line
[] . OTHER
COMMENTS
[]~/APPROVED FOR -~ . BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE
72-010 (Rev. 6/79)