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Permit (EstablishedlRecorded Lot)
Pernut (Unrecorded Lot)
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Reinspection of Existing System (Loan Closing)
Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) _ Pertnit for New Well
Improvements Permit (Addition) Replace Existing Well
_ Bacteria
1. Permit requested by:
_ Chemical
ome Phone #:� 7 — �35���6
usiness Phone #:
Tax Map#:
Parcel#: _
Township:.
_ Petroleum � _ Pesticide � Lead
. Dimensions or Proposed Structure:
Vidth:
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?
current owner: 9. Water su y type:
� private public ❑ community ❑ spri�ng ❑
Are any wells on adjoining property?Yes ❑ No ❑
If so, identify location:
: Lot size:
�� 10. Type of structure/facility: Proposed: �xisting: ❑
�zY�s TYPe of dwelling:
House: ❑ Mobile Home: Business: ❑
5. Directions to property: State Road #& Road Type of business:
ames, etc. Number of Employees:
�` , Number of bedrooms: 3
Garbage Disposal? Yes ❑ No CC�
Basement? Yes ❑ No 0'I�o, # of basement fixtures:
6. Number of occupants or people to be served:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Person COunty HeSlth 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
•,, ;�
Pert+�iit'Tssued ❑
Permit Denied ❑
Plat Observed ❑
Signature Date g
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FACfORS-51't8 fiYALiTAT10N . ARPA i €: AREA 2;: AREet 3 AREA �<:
,: _
1. SLOPE(96) S S - _ g_ _ g
PS �r 07 PS PS PS
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2. SO1L TE?CNRE (12-36IN.) S n �+ S S S
(SANDY, LOAMY, CLAYEY, NOTE 2:1 CLAY) . S/__ u ,�� /� PS PS PS
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3. SOIL STRUCiURE (12-36IN.) S S S S
(CLAYEY SOIL.S) S C�� PS PS PS
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4. SOIL DEP7'H (IN.) S S S S
� %76 •� PS PS PS
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S. RFSTRICiIVE HORIZONS (IN.) � S S S S
(a1PERV10USSTRATA.ROCK) PS rJ�j PS PS PS
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6. SOILDRAINAGFJGROUNDWAIER �G�� S S S
(EXTERNAL & IN7ERNAW P N a Y''�(T �j PS PS PS
U U U U
7. SOIL PERMEABILITY S S S
(PERCOLOATION RATE) P ���2 PS PS PS
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S. AVAiLABLE SPACE S S S S
PS PS PS
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9. SI7E CLASSiFICATION(SEE BELOW) �
SOIL SERIES
S-SUITABLE PS-PROVISIONALLYSUI'CABLE U-UNSUITABLE
K�LUMM�NDATIONS/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.SMF7NANCE.PC
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PERSON COUNTY I�EA� TH DEPARTMENT �.?� �,�
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # /� ��i Parcel # `
Zoning ,�_=��L Townshin oa S �al
Owner/Contractor % Q ���� _��_�^'� ��}"-�� :-- DateS �-`� � � _
Location/Address I 3 �'�j
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Subdivision Nam '�' � Lot#�f�,
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SEWAGE SYSTEM SPECIFICATIONS
Lot Area -�1 ��1(P uc��r Size of Tank J l�
Mobile Home�_ Size of Pump Tank N� �
# of Bedrooms�_ Nitrification Line �C� � X 3 �
Max Depth Trenches_� f � �
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or ' nd;�d��se cl}�ngfee d�
Well and Septic Layout by /� �.� .��
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�Well Permit Paid � WELL SYSTEM SPECIFICATIONS r �
Public
Site Approved_ .�
Well Head Approved.
Grouting Approved_
Comments:
Date
emi-Public Required Slab �/
aplacement Air Vent
Required Well Log
Well Tag _� /
Installed by
by,
This report is based in part on information provided the homeowner or his/her representative in the applicanon submitted �'or this permit. 'I'he
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 County nor the environmental heatth specialist warrants 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 01/95 rev.1.0
I 1 •
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LARRY H. BOIMES
DB 207 P 135
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