A35 104PERSON COIJNTY HEALTH DEPARTMENT
SEWAGE DISPOSAL
:
IMPROVEHENTS PERMIT NO.
Is ue Date: .�� - /�-
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Owner:�/ {>a.n 4 �'LtG.�-{fJ��P�:! ���5
Location.
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Septic Tank Contra tor:_��'7; C,r%,o „k S��S
Suilding Contractor:
Water Supply: Private Public
t All wells should be 100 ft. from sewer system.
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Sewage Disposal Facilities: No. bedrooms
Size of tank: ��` �
_��1 q_.�� Nitrification line:
1 'e � _
Other disposal facili
Water supply and sewage disposal facilities location, installation and
protectiion must meet state and loc.aL regulations.
Septic tank should be pumped out{every 3 ta-S, years and shall be
maintained by owner in such a-mahner as not to create a public health
hazard. Septic tank and nitrifi�ation line�HUST BE INSPECTED AND
APPROVED BY A MEMBER OF THE PERSON CO. HEALTH'DEPARTMENT $TAFF�BEFORE
ANY PORTION OF THE INSTALLATION'IS COVERED �U PUT TO USE. THZS -'�
PERMIT VOID A£TER 3 YEARS. % ^ 1 �
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Date Well Approved: Signed /{�,� �� `' iS r�: iit'.��
gy; �-�Sani ria—�' �- ,p
Date S age D' posal A proved:_ '-��, {)• �i y'
� - Counter- r,...y��) vrc.c.Ci - `'' , �-� -'--�{',
By: signed - ' U
(Ownez or his representative)
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Certificate of Completion
Date Approved: � �' � � ' �� By
Sanitarian
(Over)
Location of vell and sewage disposal facilities sketched on back.
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, Pe�son County Health Department �
Well Permit �
Date. This Perm't Void After 3 Y s I3�5- '�
Owner: ` n �� e S SR#
Locaao irections: �
Subdivision Name: Lot #
Drilling Contractor.
�" WELL CONSTRUCTION �
Distance irom Nearest Property Line Distance from Source of
Pollution �?.
Total Depth: F� reld: �GPM Static Water Level Ft �
Water Bearing Zones: Dept}� � FG Ft. FG
Casing: Depth: From V to F� Diameter. —� Inches
TYPE: Steel - � Galvanized Steel
If Steel, does owner approv �•�'� No
Weight Thiclrness: l C� o Height Above Ground: Inches
Drive Shce: Yes No
Were Problems Encoimtered in Setting the Casing? Yes No
If "yes" give reason:
Grout Type: Neat d/Cement Concrete
Annular Space Width �� Inches J
Water in Armular Space: Yes No
Method: Pum Pres�re,� Poured
Depth: �rom ��— to lJ�� F�
Materials Used: No. Bags Portland Cement Weight of 1 bag
lbs.
If mixture (sand, �/el, cuttings) - Ratio: to
ID Plates: Yes No
4 z 4 slab Yes � No
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I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS
FURTH BY THE PER O COUNTY���iIP�P�9�
Sanitarian s
AND THAT
,TIONS SET
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Issued
Sanitarians Signature Date Completed
Sketch well location on reverse side.
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NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
� supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots.
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Permit (Established/Recorded Lot)
Permit (Unrecorded Lot)
Permit (Mobile Home Replace)
Permit (Addition)
of Existing System (Loan Closing)
Repair/Replace existing Septic System
Permit for New Well
_ Replace Existing Well
1. Permit requested by:
owner/proispective owner/agent:�
A�1rlrPcc� I�a �A�� �O Q�!!tp - �i'l;
a-75 `1
Phone #: 5a�i� � S k`t
:ss Phone #: So�- (� Z4U
. Name and address of current
Description: Lot size: �
Tax Map#: I� �:
Parcel#: 1 b 4
Directions to property: State Road #& Road
mes, etc.
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Number of occupants or people to be served: �_
Dimensions or P oposed Structure: ,
dth: �i� 12eplace S�N�Ie w c��
nt}� • 1�.� 1�-I,t d o v.b l e W� �
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
9. Water su ly type:
private public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No ❑
If so, identify location:
10. Type of structure/facility: Prop ed: L'�Existing: ❑
Type of dwelling:
House: ❑ Mobile Home: Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �3
Garbage Disposal? Yes ❑ N
Basement? Yes ❑ No so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pei'SOn COunty Health Department for a site evaluation for the on-site
sewage disposal system for the above described property. I agree that the contents of this application are true
and represent the maximum facilities to be placed on the property. I understand if the site is altered or the
intended use changes, the permit shall become invalid. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
Signed Owner or Authorized Agent
Permit Issued ❑ Signature
Pegmit ��nied ❑
Plat Observed ❑
Date �
fACI'OR�SIIHEVALVAIIUN AREA1 AREA2 : 11REi13. > AitEA4 ::
I. SLOPE (9F) S S S �� S
PS PS PS PS
U U U U
2. SOiL. TEXT'[JRE (1236 IN.) S S S S
(SANDY, LOAAIY, CLAI'EY, NOTE 2:1 CLAI� PS PS PS PS
U U U U
3. SOIL STRUCIURE (12-?6 lN.) S S S S
(CLAYEY SOII.S) PS PS PS PS
U U U U
4. SOIL DEPTH (WJ S S S S
PS PS PS PS
U U U U
5, RESTRIC77VEHORRONS(IN.) S S S 5
(iMPERVIOUS S7RATA. ROCK) . PS . PS PS PS
U U U U
6. SOII.DRAINAG&GROUNDWA'fER S. S S S
(EXTERNAL & INTERNAL) PS PS PS PS
U U U U
7. SOQ. PERHiEABILITY S S S S
(PERCOIAATION RATE1 PS PS PS PS
U U U U
S. AVAII.ABLE SPACE S S S 5
PS PS PS PS
U U U U
9. SITE CLASSIFICATIOV(SEE BELOW)
SOIL SERIES
S•SNTABLE PSPROV[SIONALLY SUI'fADLE U-UNSUITABLE
RECOMMENDATIONS/COMMENTS:
STTE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.) C:WNIPRO�DOCSIAPPSEC.SMFINANCE.PC
CG47
� PERSON COUNTY HEALTH DEPARTMENT
` � WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # %���-�i Parcel # ` • �
Zoning Townshin a � s' �
Owner/Contractor � aY�o e Sfeu�cz►�7`' Date '�'/- �- 9�
Location/Aiidress �t'�l' /333 �n S�iL� /3.37 -� /33�'
S.R.# I��.S—
Subdivision Name Lot#.
Layout
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SEWAGE SYSTEM SPECIFICATIONS
epair Lot Area P� �laCv�
FD Mobile Home_�
usiness # of Bedrooms�_
Size of Tank_
Size of Pump 'I
Nitrification Li
Max Depth Tre
� Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altere ' t se c nged.
Well and Septic Layout by
'�_ Installed by
We Perm
Individual
Public
5ite Appro�
Well Hea
Gr ing A
Comments:
pproved
WELL SYSTEM SPECIFICATIONS
"�emi-Pu
Replacen
Slab
Air Vent '�
Required og
W ag —�,
This report is based in part on information provided the homeowner or h�s/her representative m tne appucanon suomtnea ror m�s permi�. i ne
environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health
specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or
misleading statements provided to him in the application. Neither Person Counry nor the environmental health specialist wartants that the septic
tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro\permit.sam O1/95 rev.1.0