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'• j�"�` - • - ArrLICATION FOR SERVICE
,,:. .. : _
Improvements Permit (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing)
mprovements Permit (Unrecorded Lot) ._ Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) _. Permit for New Well
Improvements Permit (Addition) _ Replace Existing Well
.Water Saimple to b;e Collected, �
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_
Bacteria _. Chemical _ Petroleum _ Pesticide _ Lead
1. Permit requested by:
owner/prospective own�
ome Phone #:�, 7 — ��5��
usiness Phone #: `
7. Dimensions or Proposed Structure:
Width:
;�---��— 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?
�/ , �
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d a res cunent owner: ��� 9. Water su y type:
� �, private public ❑ community ❑ spri�ng ❑
Are any wells on adjoining property?Yes ❑ No ❑
If so, identify location:
Description: Lot size: �. ��- C � �"G
. Tax Map#: ,.A�sr �� �'-�-el
Parcel#: ��� �.��, �
Township: �re��
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¢ �. Directions to property: State Road #& Road
� ames, etc. � �
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Number of occupants or people to be served:
10. Type of structure/facility: Proposed: �
Type of dwelling:
House: ❑ Mobile Home: Business: ❑
Type of business:
0
Number of Employees:
Number of bedrooms: 3
Garbage Disposal? Yes ❑ No C�
Basement? Yes ❑ No E�'I� o, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPE�tTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Person Count� 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.
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82101
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # � 3_,"�J� Parcel # � CJ �
Zoning Township ��S �].�
Owner/Contractor � ��P I I 5 h�,,..1_L Date / �--//- 4`�
Location/Address YY�GC�,�e�e`S �Vl �!1 � Y"l1 Ng��e-( C�Czv_fo�'1 1'Z�J
Lo�- a�- �.n�f r� ri -�--�_��g6� +- _ s.R.# J 39n
Subdivision Name
Lot#
SEWAGE SYSTEM SPECIFICATInNS
Repair Lot Area ,�_ Size of Tank l
SFD � Mobile Home�_ Size of Pump Tank N%
Business # of Bedrooms�_ Nitrification Line �lC� ' X 3�
Max Depth Trenches � N "
Permits may be voided if site is
Well and Septic Layout by
Comments:
Date I-�) � -q�Q Installed by
or intended_y�e cha
Approved by
ell Permit Paid Q' WELL SYSTEM SPECIFICATIONS
Individual ✓ Semi-Public Required Slab �'
Public Replacement Air Vent � ���/`� �'
Site Approved Required Well Lob �
Well Head Approvec���3��/� � Well Tag .�
Grouting Approved 'V' C ! - 13-9 $ � -�—"°�
Comments: �
Date � a(,-9� Installed by ��/ �/U k1 ;�ltw� Approved by
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The environmental health specialist is also not
respo�sible 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 health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or tnat the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
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Location/Directions:
PERSON COUNTY ENVIRONMENTAL H�ALTH
WELL LOG
Subdi�,;��on N�vme:.
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SR# �� �
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Dnll�ng Contractor. - -
WELi. CONSTRUCTION
Distance from Nearest Property Line
Distance from Source of
Pollution
Total.Dep.th: �'� Ft. Yield: �' GPM Static � ater Le F�. Ft.
Water Bearing Zones: Depth Ft. • t-
to Ft. Diameter: ��y Inches
Casing: Depth: From�_ �
TYPE: Steel � Galvanized Steel
If Steel, does owner approve: Yes No
Weight: __ Thickness: • l Height Above Ground: Inches _
Drivc Shoe: Ycs No . ' j �" !
Were Problems Encountered in Setting the Casing? Yes No
;; "ycs" give reasor►: Concrete
Grout: Type: Neat Sand/Cement -
Annular. Space Width 1 Z. Inches
Water in Annular Space: Yes No
Method: P�mped Pressure_ Poured ��
. De'�h: From O: to �� 2.0 Ft.
M a t e ri a l s U s e d: , N o: B a g s P o r t l a nd Cement______ Weight of .1 bag______lbs.
If mixture (sar�l, g�r/avel;���s) � �atio• t� .
TD Plates: Ycs �
4 x 4 slab Yes ✓� No
I HEREBY CERTIFY THAT THE ABOVE 1NFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORD�INCE WITH REGULATIONS SET
FORTH BY�THE PERSON COUNTY HEALTH DEPARTMENT.
. ,
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Signarire of Contract � Datc
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