HomeMy WebLinkAboutNEVILLA PARK LT 29 arx 'To
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REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate)
1,1amc of pepson requesting approval .. _ ....
,,amc of property, owne, ~~ ~°/
Number. of, loedrooms in house c~
~later- Analysis:
a. Bactemia].
b. Deter~ent
Well data:
a. Type
b. Depth
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c. Casing Size
Distance from well to closest existing or proposed:
1. Sewer line
2. Sept.[ c tank
3. Seepage Area
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
Flame of septic tank manufactu~.r
1. Ill "home made" show diagram on reverse side of this form.
1 Distance to property line~ /~!
' ... tO house foundation .... ~.~i'
Percolation. Test Y'esults
f, Percolation Test performed by
Use the reverse .side of this form to show diagram, Diagram should include
~ihe fo_~lowing infommation: p?operty lines~ .well location, house location,
~.'~l~e tank location, disposal area location, location of pemcolatlon test,
a~d dJr. ection of ground slope.
9. The ;n~.~ on this form is true and correct to the best of my knowledge.
Signature of Applicant ......... 'Da--re Signed ......
Jr._BE FILLED OUT BY HEALTH DEPART!,~ENT PERSONNEL
rollow~.ng conduit'ions:
Conditions: ~/gP24~¢
The above described sanitary facilities are disapproved for the following
reasons:
Approval is valid for one year following the da~e of approval.
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