A35 158. ,_ .o
� �� 1 � ° 4 ��. �
' � � "����`
� � ��
�
F
C
►-
1, permit requested by: 7. Dimensions or Proposed Structure: I
W idth:
owner/prospective own r/agent. � De th:
_ _ .., .,� .��fl � ; ..� ,�'�. L�1`�i P
a
w
U
�
a
�
z
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?
Phone #: ��97 + ��5�,6
;ss Phone #:
and a res current owner: 9. Water su y ty�pe:
v�� ��� g' private public ❑ community ❑ spri�ng ❑
Are any wells on adjoining property?Yes ❑ No ❑
If so, identify location:
, Property Description: Lot size: '�- � C ��
_ �
. Tax Map#: �
Parcel#: �
��s�
Township: '����_ �''� �
. Directions to property: State Road #& Road
ames, etc.
.
10. Type of structure/facility: Proposed: �xisting: ❑
Type of dwelling:
House: ❑ Mobile Home: Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: _ 3
Garbage Disposal? Yes ❑ No C�
Ratement? Yes ❑ No B�so, # 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 Persori� County Health Departme ont nts of thi appli� tion ahe true ite
sewage disposal system for the above described property. I agree that the
and represent the maximum facilities to be placed on the propert and that before ntImprovements Perm t can be
intended use changes, the permit shall become invalid. I underst
issued, I must present a survey plat of the property to the Health 60 DAYS after thetdate of the evaluation of t
delivered a survey plat of the property to the Health Dept. withm
the site by the Health Dept., this application shall become void and all fees paid forfeited.
Signed Owner or Authorized Agent
Permit Issi2ed C�
Permit Denied ❑
Plat Observed ❑
Signature l Date
� � lc t,J� � � t%x ��S�i'
`� \
• �t \ r
. `,�` \ i
� 2�r' /,�� . > \\
` }.
�� ::
.� ��:::,:.
." .,��;__._�:=-
`<< :,.
�`
-� .� .' _ ��
�����r � 5��.�- � 3
(�rG
_ _ _ _
_._. _ __. _ ___ _ _ _ __ _ _
?::; ' ;;�ACfORS-51'tEEYALOA7ION ':;:; ;: >i ;AREA1 ; . ;:..::. AREA'2 AREA3 AREA;t .
1. SLOPE (Rr) � S S S
.. PS 0�,� PS _. PS PS
U U U
2. SUtLTEX7l1RE(12-361NJ S S S S
(SANDY, LOMfY, CLAYEY. N07E 2:1 CLAY) - � PS PS PS
� `�"� �-�� U U [J
3. SO[L STRUCTURE (12•361N.) S S S S
(CLAYEY SOILS) S S� PS PS PS
U U U
4. SOIL DEP'IH (IN.) S� S S S
/a� 73 �'� PS PS PS
IT < U U U
5. RESTRIC7'IVE HORIZONS (IN.) S S S S
(IIv/PERVIOUS STRATA. ROCK) �� PS PS PS
U U U
6. SOILDRAINAGF/GROUNDWA7ER S S S S
(EX7ERNAL& IN7ERNAL) �s—� � �D PS PS PS
t� r�. o l� u u u
7. SOIL. PERk1EABILITY '- S S S S
(PERCOLOATION RATE) S � 3�L PS PS PS
U U U
R. AVAILABLE SPACE S S S S
PS o1l PS PS PS
� U U U
9. SiIECLASSIFICATION(SEEBELOW)
SOfL SERIES
S•SUITABLE PS-PROV[SIONALLYSUITABLE ll•UNSURABLE
RECOMMENDATIONS/COMMENTS:
STTE CLASSIFTCATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.� C:WTIIPRO�DOCSIAPPSEC.STiflNANCE.F'C
.• �
;
�
'_ARRY H . BOIMES
DB 207 P 135
�
a
� . _ J
^
�
RONALD M. CLAYTON �
DB 204 P 827 � y'
0
�'S2 �
KENI+�TH L . CLAYTON
Dg 199 P 253
i �
1 ' '
�
� r '
'E � �
►
AL � 3� IF t�''
1S� ,
33.07' �
�ES �
l-.
� o� ,
� .� �
��`p � ^ �
p � �
� ~
� I y '
� � �
IS
!iS 3
32.00' � `
y� ' J, �• .
��f s"
(��3 ' g� ,
a �' N � � O
y I co
� .o
� o,
�3 �►��
s' �.�� ,
;/���/�
O ty � �/
/ � ' -
1 p � �
N � � .
:
t-nV
"/
\
` PERSON COUNTY HEALTH DEPARTMENT
' WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMII�
Tax Map # � _3 � Parcel # �
Zoning Township c
Owner/Contractor '� / Date��
Location/Address �� ,/ 33 3� Sr �- / 5 5 7 -�v Sc �/� � c
A��� 008
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered ' ten d u cha ged.
Well and Septic Layout by
Comments:
Date �-���}-��, Installed by /(�rY,_,P, ►1� Approved by
a_-� 9_ �� WELL SYSTEM SPECIFICATIONS
3ividual_�Semi-Public Required Slab
�blic Replacement Air Vent �
te Approved Required Well Lo�
ell Head Approved Well Tag 1/
�outing Approved - � � `
Comments:
Date ''`' Installed by K/-,- W I � ���t � sy-- Approved by
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this ernut The
environmental health specialist is not responsible for false or misleading infoanation co:rtained in the application. The environmental health specialist
is also not responsible for concealed conditions on the propetty or for statements in this report that may have resulted from faLse or misleading
statemecns provided to him in the application Neither Peison County nor the environmental health specialist warrants that the septic tank system will
continue to function satisfactorily in the futwe or that the water supply will remain potable.� c:�amipro�pennitsam Ol/95 rev.1.0
Sn�.
133 �'%
• • � V
Date:
OwnE
Location/Directions:
�
l'Lilt:.iUN (:UUN'1'Y I�:NV 1 Il()NMI•:N'1'AI. III•:AI,'I'll
WELL LOG
♦
�
sR# 39
Subdivision Namc: . Lot #
Drilling Contractor: � k�� ���� M S N G'
WELL CONSTRUCTIO
Distance from Nearest Property Line Distance from Source of
Pollution —
Total.Dep.th: _ Ft. Yield: 1 GPM Static Water Level Ft.
Water Bearing Zones: Dep Ft. Ft. F� / Ft.�ches
Casing: Dep t h: From t c.�_ F t. D i a m e t�
TYPE: Steel � Galvanized Steel
If Steel, does owncr approve: Yes_No
Weight: Thickness: . �� _ Height Above Ground: Inches
I?rive Shoe: Yes No_
Were Problems Encountered in Setting the Casing? Yes_______ No
I: "ycs" givc:�ason:
Grout: Type: Neat _ Sand/Cement Concrete __
Annular Space Width �Z. Inches
Water in Annular Space: Yes No______
IViethod: Pwmged� Pressure_ �'o�� ✓
Depth: From � to � Ft.
Materials Used: No. Bags Portland Cement_. Weight of .1 bag_lbs.
If mixture (sand, gravel, cuttings) - Ratio: _ to -:
ID Plates: Yes� No_______
4 x 4 slab Yes No _
T HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT `
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON COUNTY HEALTH DEPARTMENT. �
, , � �,-4 6
Signature of Contrac . Datc