A35 138n
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! . _ Pezson County H�aith Deps.rLaent
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I DATE tbSUE s ! W1 B DRILLED:��--�����OUNTY: e
OfQiEA � RO1►D /STREET s
ACORifS:
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' �� ADDRESS
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MSLL CONSTitUCTION i
� Distapce lrom Nearest tsoparty Line Distance from Source of
, Pollutioa ``� , • _.... . i
_. :_ -_ .. . �
Total,Depth: . t. Yield: �;PM S[atic Water Level Ft_
Mator Il�asing ZOnea: D� � Ft. Ft� � Ft. �
j. Casing� DeptDr Froa�_to'�( �_gt, piamet�r: �,i`� 1 Inches 1
i'YPE: Steel Galvanized Steel ;''
If Steel, does ovner app Yes No
� Waightx " Thickness:�eight Above Ground: Inches
Drive SAoa:. Ysa No �
� Rere Probleos Encountered in Setting the Casing? Yes No_
If ' es' — t'
y givm reason: �,
Grout: Types Neat Cement Concrete
1lnaular Space Midth� _I;,ct�es
+ Mater ia ]lnaular Space: Yee _No J
i -- � ,
�.. llethod: pumped� P�� re Poured
Depth: From ,'4„i to �� Ft.
Matarials Usad: No. Bags Portland Cement Weight of `
1:'bag lbs. �
_ --- -
"Tf'mixture (sand,-gr�vel; cuttingsf - Ratio: - _--to -. -_._..::}
` ZD plates: Yes f•e�` . No �
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{ x � alnb Yes .•�.v` xo 1
� � DRILLING LOG �
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F� To Formation Descriotion j
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, , I HEREBY CSRTIFY TiiAT THE ABOVE INFORM]►TION IS; CORRECT AND
fiEI.L Ml1S CONSTRUCTED IN 1►CCORDANC =1i.�� H�EGULATZONS SST
PERSON COUNTY BO]►RD UF HFALTH. P i �' V AFT ' THREE �
�� ���'� �,��
Sj��kur�of Contractor
tarian's
�T THIS '
!T BY THE
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Oate
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Date Issued
� Sanitarian's Signature Date Completed '
Sk�tch wll locatioa on ravezse side.
Appiicatio� Date: 7 — �� ��
Amount Paid: I�S�T�
Receipt #: 2 7�
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� a�a_�as-oaa��-•--�• ox�a�m71 ��m�71�1�a
APPLICATION FOR SEiZVICES
Improvements Permit (Recorded Lot) - $200.00
Improvements Perrnit - $150.00
(Mobile Home Replacement/Addition)
RepairlReplace Existing 5ystem Pertnit
Taz Map #: �3�
Parcei #: -13 �
Well Pertnit (New/Replacement) - $225.00
Consfruction Authorization for Septic Systems-
$150.00/$200.00
Pertnit Revision Fee - $75.00
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED,
CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHAL�. BECOME INVALID. � `
1) Permit requested by: wne gent/prospective owner):�'O.�A �1 �✓' �/����
Home Phone: � � ¢ -� -`r � z `/ Address: /�/o K�ssa.�G Ci.a���.J %�C�
Business Phone: S/4 -S�/y -��90 ,� .�o. �,1�G. �. �.�� �
2) Name and address of.current owner:� ��' �� �' � �
/ya f-�A-rs..e<c. �/� r2�Z
/?o/'CGa/to r�•C• 7_'��7�
3) Property Description: Lot sizea?�fl ��ownship:�'�d���a.-Subdivision:
Directions to the property (including road names and�umbers): %�A-[�1-�� Lr�,lc.�a- �
•��, /� �►.� ��.. .,�.�.- ti float� �PD �' n rs C/f u.l�s C
� �a �
i
-�� o s;bl�e
� �- Q �o; � ed
p�� � a.,
Lot #
,��,� � {,�„ � �.Q� ru RJ .2 .,..� �1�s sell C� ,as.,�.._ .z.�_ _ � 3 �j a
32v fFmHsa- � �%�� f- .
4) Proposed Use and Structure Description: answer each of the following questions: ' ,
a) Proposed , Existing _, Type of Structure: 7¢f�t�-/-1 �� �%�i�4-��- Width: d�G Depth: tP" �
b) Number of Bedrooms: �_ Number of occupants or people�to be served:
c) Basement: Yes , No _,,,� Wiil there be piumbing in the basement?
d) Garbage Disposal: Yes , No .�
5) Water Supply Type: Private �(new _ or existing�, Public , Community , Spring _
. Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the
� site plan.
6) Does your property contain previously identified jurisdictional weilands? Yes_ No_
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPl.ICATION.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. �
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF. '
I hereby make application to the Person 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. 1 understand if the site is altered or the intended use changes, the permit shafl
become invalid.
�- ��
Owner or
Representative
7 ?- G �7
Date
PCHD, rev. 06/27/02
�...
. ��5, r3�S
t�erson County Heaith Department
►ewa� e System Imp�rovements Permit
i����e' -��"•s pe�c vQi��' s.Years, . .
SR#
�ubdivision Name: � � ' Lot #
LoC'Size:. , c vtei� Type of Dwelling.
Water Supply: ,`vate• Public• 1 t'�
Semi�Private:_ � � If not Private Tax Map#
Pancel # of Water Supply or Name of
Supplier#
Bedrooms: __� Garbage Disposal__.��j�
Basement Basement Fixtures ' %
$8111t8I1aI1: ) - � - c•� � -
o er or apiesentative
REPAIIt• REE ALUATION: � 'v
SizeofSepticTank• � _`_----------- �
Ni � __�� gall°�s •—
trificabon Line: - 1 R1� ��3 � �
Deptti�of Sfone: 1� mches �
Max Depth:of Trenches: �
OPERATIONAL PERMIT; yes.,� no
�Iil�CS:
Date �Vell A-- .�f 2��0 Wel! should be 100 h, from any sewer yystem
BY 5anitarian
n� - �, _ ,� . �� _go
BY Sazutanan
^w f�...��� � .� tT�iCATE OF COMPLETION �
Wnu{N.� -�< �_
5ewage System location. installad �
on, and protecdon must meet state and local �
'�8ulaaons. Septic taak should be pumped out every 3 to 5 years and shall be
��� bY o�� in such manner as not to create a public health� hazard.
iepdc tank and nitrification ]ine must be inspected and apprrn,ed by a member of
he PersOn County Health Dep�ent before anY porqon of the installation i.4
�vered �and put into use.
.ocation of sewage disposal sewage system sketched on back.
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Tax Map #$� Parcel # ��_
Existing Sewage System Report For. �,/� obile Home Replacement
V Addition Type: (k-� � cd �aa ra
Requester. � c'�(1cL�� �.,�, C�G�' �Sl Home Phone�5q9 _ I a 4
.�,��{-�L6 �5 � (( C/�� � i� - Business # C�9��0 %a
Dx��o, �� a �s- � 4 � �
Location: C�L1� I�CtKC. �C�'� mL�l7CtS /� F��� �<`""J �lCif.s�i�
Original Permit Located: � Water Supply:� il UU-i2- (.•� C((
Septic System Designed For: �Residential Business Other
# Bedrooma <J # Employees Other
System Type: �r1 ��-(�{�`On�- ( 'Tank Size: Nitrification Line: ���X U/
Date Installed: r� �a �� � Certified Operator Requited: � �
On-site wastewater disposal system showa no visual aigus of malfunction on �� r �.
Permission is granted to: ��� �d a- C�� �-c� c� �i a r� q�, C%5 5 h oc,,�n ..
%c c� q a �Q y c. �� F�oM �. � c- �l � 3c� " F�nM
�
Environmental Health Specialist
Date: �^� �
__ _ _. _. _ ..__. . ..
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]E.�m�a.�roa* � e��m.]L IE-T�mIl�
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N �Ona(ci ��a��0� ---, TazMap #��P��1# /38
S 1 • � Secti�on/Lot#
� ,� ' '"'I -q -03
� Authorizeri State Agent - . � Date . .
System cmm�ionemis �r�ssait ap���contmurs ossly. Z'3se �r must, flag tlre s, yste�sa j�ra�r ��
dseg�g �ha a�atal�4ion #o ittrure t�aat�iropergs�de ss marntaa�red
s�.� N o �E �
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I'G�i�3, sev. 9/12/01