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• APPLICATION FOR SERVICE
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1. Permit requested by: �p}-�nr�� � 7. Dimensions or Proposed Structure:
�wner/prospective owner/agent: [�a.�� C-���� Width:
Address: Depth:
C0.ve1-
0
u� l.aic e �d
a� s3
ome Phone #:�G ► c�� 5q1- 35� �
usiness Phone #:iG►oi�►� - 8�
Name and address of current owner:
��
Description: Lot size:
. Tax Map#: �1 -s =
Parcel#: � �
Township: C � � ►� i .0
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a¢ 5. Directions to property:
z Q�es, etc.
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F uS5 Hu}� � c
iJr�no .��. (�v� l��-� -�l
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Road # & Road
Number of occupants or people to be served: a
8. What type (if any, additions, expansions, or
replacement is anticipate�l to the structure or facility
that this sewage disposal system is intended to serve?
�,o� � le hu me �.oare� h" _ -� home
� r-, � - -
9. Water supply type:
private E-� public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes � No ❑
If so, identify location: f3Y�ck- 1��c o� �
�.� �..0 ,� �-.r,.� f wvl�. r 1�. C�,r,r� �'s �rne
.
10. Type of structure/facility: Proposed: C�Existing: ❑
Type of dwelling: � ,�rt�►{-�a-QS�t,) �'�'�e
House: ❑ Mobile Home: I�'Business: ❑ �`''���
Type of business:
Number of Employees:
Number of bedrooms: �-y
Garbage Disposal? Yes ❑ No �
Basement? Yes ❑ No Ca'If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Person County Health Departmerit 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.
� �' �-� �, �_ �� ��"''
' ned O er or Authorized A ent �
Sig S
Permit Issued ❑
Permit Denied ❑
Plat Observed ❑
Signature Date
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" " PACl'ORS-SITEEVAL[IATION ;; ... ': '; t1RE41. , ,: ;= AREA2:; AREA3 ARFAd:i'
_ _. _._ _ : _ _._... . .
1. SCAPE (%) 1 $ S _ S
PS U .- ��� PS � . . � PS PS �
U U U
2. SOII. TE7C7URE (12-36 IN.) � S S S
(SANDY, LOAMY, CLAYEY, N07E 2:1 CLAY) PS � �[/ PS PS PS
�'�`� U ' U U
3. SOIL SiRUCTIJRE (12•36IN.) S S S
(CLAYEY SOILS) _ P ✓�/y(Z PS PS PS
����'� U ' U U
4. SOiL DEPi'H (IN.) � ' � Q � S S S �
' �% << PS PS PS
�� U U U
5. RESTRICi1VE HORIZONS (IN.) S S S S
(Qv1PERVIOUS STRATA, ROCK) N� PS PS PS
U U U'
6. SOIL DRAINAGFIGROUNDWATER S S S S
(EX7ERNAL & ATiERNAL) S �D PS PS PS
U U U
7. SOIL PERMEABILITY S S S S
(PERCOLOATfON RAiE) S ��—� „,3 PS PS PS
U U U
8. AVAILABLE SPACE S S � S S
PS {� � PS PS PS
U v� U U U
9. SITE CLASSIFICATION(SEE BELOVI� �
SOIL SERIES
S-SUiiABLE PS-PROViSIONALLYSUiiABLE U•UNSUITABLE
RECOMMENDATIONS/COMMENTS :
STI'E CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.� C:V�r1IPRO�DOCSUIPPSEC.SM FINANCE.PC
' � B0162
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� PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT
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.
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Tax Map # � .� � Parcel # � I lo � !�� � 1�_
Zoning Township
Owner/Contractor o n n � Dat 1- -2 !� - �% �c
Location/Address ?
s.R.# 3 �7s
Subdivision Name
Lot#
SEWAGE SYSTEM SPECIFICATIONS
_
E�epair Lot Area �� c•r� Size of Tank ���U 5,�'�-(/����'
—�
SFD Mobile Home ,/ Size of Pump Tank N�,�
Business # of Bedrooms � Nitrification Line ��� � �C � �f -�- �-��n,,�„-
Max Depth Trenches �L "
Permits may be voided if site is altered
Well and Septic Layout by
Comments:
Date ' � � Installed by --� � �
4:� � i° e
Well Permit Paid WELL SYSTEM
Individual Semi-Public
Public eplacement
Site Approved
Well Head Approved
Grouting Approved � 2 Z-�
Comments:
Date
Installed by
0
0
Approved by,
q .S� �
ATIONS
Required Slab _
Air Vent
Required Well Log
Well Tag
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
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 health
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 O1/95 rev.l.l
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IF
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260.00' TOTAL NS
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Date: '7— 17�5' �'
Owner: .�� < G�n
Location/Direc ions: �.
�ubLivision Namc:
Drilling Contractor:
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
�..
SR# /3 �� �
i .nr #
Distance from Nearest Property Line �s Distance from Source of
Pollution_,,�6� � " �
Total.Dep.th: D Ft. Yield: GPM Static Water Level Ft.
Water Bearing Zones: Depth _��FC. Ft - F� � �t.
Casing: Depth: From D to '�%� Ft. : Diameter: �' Inches
TYPE: Steel - Galvanized Stee1 - � �
If Steel, does owner approve: Yes No
� Weight:�3 Thickness: ,Height�Above Ground: Inches
Drive Shoe: Yes �� No � �
Were Problems Encountered in Setting the Casing? Yes � No_ �
If "yes" give reason:
Grout: Type: Neat Sand/Cement '� Coricrete
Annular. Space Width � Inches
Water in Annular Space: Yes No v
Metho.d: Pumped . Pressure Poured c� - .-
Depth: From �_ to � Ft. � - �
Materials Used: No. Bags Portland Cement� Weig}it of .l bag_lbs.
If mixture (sand, gravel; cuttings) - Ratio: 2— to
�ID Plates: Yes�_ No � � � � � � � �
� 4 x 4 slab Yes J No
I HEREBY CERTIFY THAT THE ABOVE INFORM�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH �3Y�THE PERSON COUNTX HEALTH DEPARTMENT.
. - f�/ C-�'7�---�'f/ / �� _ _ � " � � � (�
Signature of Contractor Date
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Amount paid jDCj�d—
Receipt .4� ' ] � 4`1 6
.•. 'y � • +v1'L3 � ��� nnT.r�`ATION FOR SERVICES
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� Date
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�mprovements Permit. (EstablishedlRecorded Lot) ._ Reinspection of Existing System (Loan Closing)
Impxovements Permit (Unrecorded Lot) ._ RepaidReplace existing Septic System
Improvements Permit (Mobile Home Replace) _ Permit for New Well
Improvements Permit (Addition) _ Replace Existing Well
�s 'fi = � r: � r � ' 'S�ater Sample.to be Collecfec�. ., �
....; ,.. . : .>M
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... _,.. . ....� . . <. .�. ..� .
_� Bacteria ^ �_ Chemical _ Petroleum _ Pesticide
1. Permit requested by: .
owner/prospective owne�
ArlrirPcc' . 4Q�Q _��l1U
�
7. Dimensions or Proposed Structure:
i4�dth: `l C) �C 4 4
_ Lead
3 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?
ome Phone #: � � � Sg�"35a 1
usiness Phone #: 3�' ��� �''�9 �-�'�'�"`� S>
,.-.c o r k
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and addre�s of current owner: 9. Water su y type:
ti��_� �� �'�,n�-i�� a private public ❑ community ❑ spring ❑
��uj,,�� Q� Are any wells on adjoining property?Yes ❑ No �.
,.,,,.,, n�.C' _-�n�13 If so, identify location:
Description: Lot size: � �� � ��'-
Tax Map#: � 3s
Parcel#: 1 � b
Township: ��� ' �' a'�^
Directions to property: Sta e Road #& Road
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Number of occupants or people to be served: .�_
10. Type of structure/facility: Proposed: �xisting: Q I
Type of dwelling:
House: C��iobile Home: [� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �
Garbage Disposal? Y ❑ No �
Basement? Yes Noi� If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pet'SOn COunty Health Depat'tment for a site evaluation for the on-site
sewage disposal system for the above described property. I agree that the con[ents of this application are true
and represent the maximum facili[ies 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 presen[ a survey plat of [he 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.
Permit Issued ❑ Signature Date •
Permit Denied ❑ � -
Plat Observed ❑
v a., ,. �'r<r...,, t. ,:: FACI'ORS$TfE£VA1.11A770S�F;' ., . <:;. '�; . ..:.: .. <x�I�Jit. ' . ARFJ�2 i!' AREh3 , c ARFA4 .Y .
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1. SLOPE (%) S S S S
PS PS PS PS
U U U � U
2 SOR,7EX7VRE(12•36IN.) S S S S
(SANDY, LOMiY. MYEY. N07E 2: t CLAI� PS PS PS PS
u u v u
]. SOIL STRUCNRE (12•36 IN.) 5 S S S
(MYEY SOJI.S) PS PS PS PS
U V U U
3. SOILDEPIN(INJ S S S S
PS PS PS PS
U U U U
3. RESIRICI1VEy0RtZONS(IN.) S S S 5
(IMPERVIOUS STRATA. ROCK) PS PS PS PS
U U U U
6. SOILDRAINAGE/GROUNDWATER S S S S
�F�7'�NpL q INTERNq�� PS PS PS PS
U U U U
�. son�xMEns�unr s s s s
(PFRCOLOATION RATE� PS PS PS PS
U V U U
E. AVAILABLE SPACE 5 S S S.
PS PS PS PS
U U U U
9. SCfECLA$SiFICA710N(SEEBELOW)
SOIL SERIES
S-SUITA6LE PS-PROV1S10NALLYSUITADt,E U-UNSUTfABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, �11
areas, wells, water bodies, slope patterns� eIC.� C:NMiPRO�DOCS�APPSEC.S�1 FWANCE.PC
Yerson County Health Department
Existing Sewage System Report For: � Mobile Home
Addition
- • ri � ,� � �tr�.
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Location/Directions:
-�/.� nn . � „
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Original Permit Located
Septic System Uesigned For:
Kesidential _� Business _
# f3edrooms �_ # Employees
�l�% '`.:, : .
Replacement �N�.
Home Phone# �%7�3c�jo� �
Business# ��� �3%9
'Pax Map# Tt�J' � b �
�t-.- 11'lC��-�n,�'S �Vl � 1� �(.
� n �--es�
Other (speciEy}
Other
Uate :Lnstalled �'"S � 1�p pply �i
Water su ��=
'Pype ot System
Nitritication Line —1,.c�`� �(. �"
Tank Size � ���
Certified Operator Required l VU —
On si�e wasL-ewater disposal system showes no visually apparent
malFunction on �/ / / / �
Yermission is granted to: �
According to the attached site plan.. -
C o mm e n t s: , _�`3"' � �"�� �C�� ����1s
Environmental. Health Su v. � -��
DATE
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