HomeMy WebLinkAboutSNOW CREST VIEW LT 23LC)l
REQUEST<Fd�AL OF �'
INDIVIDUAL SEWAGE AND WATER FACILITIES J ` ,
(Fill out in Triplicate)
13ame.of person requesting approval � �
2, dame of property -owner
3. Legal_ description
4. Numbez.of bedrooms in house
�J
5. Water Analis:
a. Bacteri_a1
b. Detergent ,
6. Well data:
a. Type
b. Depth
c. Casing Size
d. Distance from well to closest existing or proposed:
1. Sewer line d��e
a
2. Septic tank Gf%
3. Seepage Area
4. Cesspool -
5. 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
c. Name of septic tank manufacturer
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
r
h
e. Percolation Test results
7 f. Percolation Test performed by
t
0. Use the reverse.side of this form to show diagram. Diagram should include
the
following information: property lines' -well location, house location,
1��Fn-ic tank location, disposal area location, location of percolation test,
azid direction of ground slope.
9. The Irl-forumstion on this form is true and correct to the best of my knowledge.
Signature of Applicant Date Signed
TO BE FILLED OUT BY HEALTH DEPARTMENT PERSONNEL
The above described sanitary facilities are hereby approved, subject to the
rollowing conditions:
Conditions;
_t
The above described sanitary facilities are disapproved for the following
reasons:
0
Sig atu , of f9fiei ;etc'
` Date r, •:,,.,
Approval is valid for one year following the date of approval.
CPJ:cw
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate)
��. 'Name of person requesting a proval
2. Name of property -owner `
3. Legaldescript.ioq
4. Number -o£ bedrooms in house
5. Waters -Analysis:
a. Bacterial
b. Detergent
6. Well data:
a. Type
b, Depth
e. Casing SizeU
d. Distance from well to closest existing or proposed:
ti
1. Sewer line
2. Septic tank
3. Seepage Area
4. Cesspool'
5. 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 l :�
c. Name of septic tank manufacturer
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
V'
e, Percolation.Te•st -results
f. Percolation Test performed by
�- Use the reverse.side of this form to show diagram. Diagram should include
3,he fol_luiing information: ppoperty lines;•well location, house location,
»,1:9c tank location, disposal area location, location of percolation test,
al>d direction of ground slope:
9. The rr,-f<,r�ira_t-lon on this form is true and correct to the best of my knowledge.
Signature of Applicant Date Signed
TO BE FILLED OUT BY HEALTH DEPARV ENT PERSONNEL
the above described sanitary facilities are hereby approved, subject to the
`llowing conditions-
Conditiors :
�i
0
The above described sanitary facilities are disapproved for the following
reasons;
Signature of Ftficr ;a,; << ..• ;'• "'__"----
Approval is valid for one year following the date of approval.
CPJ:cw