HomeMy WebLinkAboutABBOTT LOOP MANOR BLK 1 LT 50 Id- I '1-
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.of person
2. flame, of property~owner
3. LeFal description
Number 'of ~bedrooms in house
WaterAnalysis:
a. Bacterial_ ~.
h. Dete~Eeot' ''
B. We~l data:
b. Depth_
c. Casin~ Size
Distance from well to closest existinz, or proposed:
1. Sewer
2. Septic tan~ ~'~
Cesspool'
5. Property Line
Other sources of possible contamination, I.e., creeks, lakes,
houses, ham, dralna£e ditch, etc. . ~
c. Name of septic tank manufsctu~
1. If "home made" show diaFram on reverse of this fo~m.
d.' Disposal field o~ seepage pit size and ty~e
'Distance to'p~ope~ty line ~_~.__to house foundation.,, ,~),~;
9®
f. Percolation.Test performed by
Use the rover-se .side of this form to show dia£ram. Dia~ra~ should include
.-the foilowin~ lnfo~.ation: ~operty lines;.well location, house location,
~pt~c tank location, disposal area location, location of percolation test,
aE~ di~ection of Kround slope.
The ~,£~x,mt~on on this form Is true and correct to the best of my knowledge.
~ Date $i~ned
~0 BE FELLED OUT BY REALTH DEPART~.~Et~T PERSONNEL
The above described sanltar~ faollitf~s are hereby ~pproved, .subject to the
Conditions:
The above described sanitary facilities are disapproved for the following
Date .:'
"Approval'as vdlid for one year following the date of app,'oval.
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