HomeMy WebLinkAboutHERBERT LT 2CLo'F xc
A
115'
)~ ' / ~k~ / INDIVIDUAL SEWAGE AND WATER FACILITIES
~k~ ./ (Fill out in Triplicate)
2 ~"' ~ame of property~ owner
3. [.a y~al das~criptio% ~/
, //~ ~ r~ ~
WatenAnaly$is:
b. Detergent ' ""'
6, Well data:
a. Type _
b. Depth_.~
c. Casing Size
O( -
Distance from well to closest existing or proposed:
1. Sewer line
2. Septic tank
3, Seepage Area
4, Cesspool'
5. Property Line
houses, barn, drainage ditch, etc.
7. Sewage disposal system,
a. Age of system
b.
Other sources of possible contamination, i.e., creeks, lakes,
Septic tank capacity in gallons
c. Name of septic tank manufactu~e.'r
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
e. Percolation.,T~st~es~Llts
f. Percolation Test performed by ..... --4'
Use the reverse,side of this form to show diagram. Diagram should include
'%he foil,owing information: p~operty lines~.well location, house location,
~'~,~c tank location, disposal area location, location of percolation test,
a~ d~rmction of ground slope.
9. The i-n~,:,~,,~.~tlon on tkis form is true and correct to the best of my knowledge.
S~gnature of AppilCa~t''
Date $i~ned
FILLED OUT BY HEALTH DEPART~.~ENT PERSONNEL
above described sanitary aclllt~es are hereby approved, subject to the
~r~6'llowing cond.i.ttons: ' '
Condit ion,z :~ ~. ~.~,-
The above described sanitary facilities are disapproved for the following
reasons:
Approval is valid 'for one year following the date of approval.
· CPJ:cw
w ~oxw~
4