HomeMy WebLinkAboutSUNNY SLOPES LT 53
(Fill out in T~iplicate)
Name .of person requesting aporoval /~ L, iO
Name of property owner ~j,~;~.~ ,~ ~ ~
~REQUEST FOR APPROVAL OF k~'
INDIVIDUAL SENAGE AND WATER FACILITIES
3. Legal description ....
Number of bedrooms in house
5. Water Analysis:
a. Bacterial ~ .
a. Type
b. Depth /' __'
c. Casing Size
d. Distance from well
1. Sewer lin
closest existing or proposed:
Septic ta]
Seepage Area
Cesspool2
7. Sewage disposal system. ~ '-
Property Line
ther soumces f .poss ble contamination, i.e., creeks~ lakes,
~ouses~ barn,.~aznage ditch, etc._.
a. Age of system~l~,
b. Septic tank capacity in ga]ions__~O00
c. Name of septic tank manufacturer ~( ~ ~6~6
i. If "home made" show diagram on reverse side of this fomm.
d. Disposal field om seepage pit size and type
1. Distance to pPoperty line_ /.5~/ to house foundation
Use the reverse side of this form to show diafram Diagram should include
the following information: ~op'rty .lines; .well location, house location~
septic tank locations disposal area locatlon~ location of percolation test~
and direction of ground slope.
Percolation Test results
Percolation Test performed
The information on this for~ :s true and correct to the best of my knowledge.
Signatur~ bf Applicant --' Date Signed
~O BE FILLED OUT BY HEALTH DEPART~.!ENT PERSONNEL
.ne above described sanitary c~i~t~es are hereby approved, subject to the
fa ....
......... ~'llowing cond~i~ons: _
Conditions: ~ / ~
The above described sanitary f ,' · ' ·
reasons: acllltleS ape dlsspproved for the following
Dat~ .~," f~.>.~, :,~..,~
Approval ~ ~alid for one year following the date of approval.
CPJ: cw