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MIDLAND HEALTH and
   SENIOR SERVICES

 

(432) 681-7613
FAX (432) 681-7634
3303 WEST ILLINOIS, SP. 22
P.O. BOX 4905
MIDLAND, TEXAS  79704

SITE EVALUATION

DATE:_________________________________

APPLICATION NO.______________________

     Name________________________________________ Phone___________________________

     Street or P.O. Box_______________________________________________________________

     City_____________________________ State_______________________ Zip_______________

PROPERTY LOCATION:

     Lot_________________ Block___________________________ Subdivision________________

     Street Address_________________________________________________________________

     Unincorporated area (  ) or City____________________________________________________

     Additional Information____________________________________________________________

Drawing of Site             >>>  
1.    Show compass North, adjacent streets/roads, direction of slope, property lines with footage.

2.    Location of holes (numbered); show distance from property line.

3.    Location of existing or proposed wells.

4.    Location of natural, constructed, or proposed drainage ways, water impoundment areas, cut or fill, tanks, buildings.

5.    Additional information that may influence the function of the proposed system:

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