A35 1616�� _ � � s. �o
. «�-�! �-�����n
�
H
O
�
W
U
�
a
,. �
APPLICATION FOR SERVICF,S
, :;;; .>:;. _ _
Improvements Permit. (Established/Recorded Lot) ._ Reinspection of Existing System (Loan Closing)
ImpFovements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) _ Permit for New Well
Improvements Permit (Addition) _.._ Replace Existing Well
Water Sample to be :Collected: , �
; , ... ..:. :. . . ..
Bacteria Chemical Petroleum Pesticide _ Lead
1. Permit requested by: .
W
�
z
ome Phone #:�
usiness Phone #:
7. Dimens' ns or Proposed Structure:
�►�/�'i�� Width: � ��
'����--- 8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
� that this sewage di�al system is in � ded t� e
� �,�.(-, /.� , m �- �ir�Ga� P�
and addres of.cunen owner: 9. Water supply type:
� , � �/ private'� . public ❑ community ❑ spring ❑
h Are any wells on adjoining property?Yes ❑ No [j.
,/,��� �, y,J� _� / � If so, identify location:
. Property D
. Tax Map#:
Parcel#: _
Township:.
tion: Lot size:
. Directions to property: State Road #& Road
/aaJ �
_ / 5,
Number of occupants or people to be served: �_
10. Type of structure/facility: Proposed: �Existing: Q �
Type of dwelling:
House:� Mobile Home: � Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: -�
Garbage Disposal? Yes ❑ No]�
Basement? Yes ❑ No�1 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 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.
A
, � 2: ��
Signec� Owner or Aut
Agent
:_ .�
Permit Issued ❑
Permit Denied ❑
Plat Observed ❑
���
� �
�.
w�
Signature Date
� �v � Vh �fS
� ��r�s���
��
�Q� ���
H�
�
�,
.:��/� -��
., � .
_ �� • - ,.
��
�; FnCrORsstre �vni.unnort :: ,;:: `: ;`Ax�► E :i...... ' .. n[�2 ;: .,, axEn3 ,'; z . Ax&�'s
, .
t. .. .. ... . . :: ;
_,: ,<,. ,
i. swee c%� s s . s
PS D� r(S7� PS PS PS
, i C V U U
2. SOII. TDC?URE 02-36 iNJ S S S S
(SANDY, LOAMY. CI.AYEY. NOTE 2:1 CLAn ��Y � V U U
Q
3. SOIL S77tUCilJRE (12•361N.) S S S
(CLAYEY SOII-S7 PS PS PS
U ��i U U U ,
4. SOILDEPfFi(IN.) S S S S
S �/ �� PS PS PS
b U U U
S. RESTRICf1VEH0RI7ANS(IN.) S 5 S
(AlPERVIOUS STRATA. ROCK) S � � PS PS PS
v u u
6. SOILDRAINAGFJGROUNDWATER S S S
tDCIE7tNAL � IN7'ERNAL) � N� V U PS
U
�. SOIL PERMEABIL]TY S S S S
(PEACOCAAT(ON RATE7 S � 2�L PS PS PS
J u u u
8. AVAILABLE SPACE S S S S
� PS PS PS
U U U U
9. SiIECLASSiFICA710N(SEEBEIOW)
SO1L SERIES
S-SUITAIILE PSPROVLSIONALLYSUITABLE U-UNSllTfABLE
RECOMMENDATI ONS/C OMMENTS :
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etC.� C:�AbifPRO�DOCSAPPSEC.5T1 FWANCE.PC
,�... __ , . _
. ,�,� �-� �- . - �- -<.- .:. ;.,•.
�oo ; . zoo
� �
�1 inch = 50 ft. :
�
__.. ..�, �:_. ._ .:_.. ._ . . __.._. ;� .-- � �
___�^__, _ . � � r,�� y � . �. , �,«,�,qA � cor
� ��� �l�i1t S�✓t � ,,�:. � COF
,�� �34,49"E� S83 19'42°E� IF�
� NS�-N8� a . � -6� o....
!� �7� �_
��' �—
� � r �:. �� � � J
_�,�
� �� • '� �
� � W
� rb�l �
ry a
ALMA R. EVANS
72-E-82
(WE ARE) THE OMNER(S)
tED HEREON, WHICH WAS
:DED IN THE PERSON
:N BOOK ____. PAGE ____
; PLAN OF SUBDIVISION
ILISH THE AIINIMUM
ALLEYS, KALKS, EASEA�ENTS,
(C OF PRIVATE USE AS NOTED.
iAT THE LAND AS SHOMN HERE-
JLATION JURISDICTION OF
ISION PLAT AS DEPICTEO
PROVAL PURSUANT TO THE
TIONS.
� . � � !2-�,�
�ND ZONING�►AINISTRATOR
NS
�
�,
a
O o` ��.
�a^^� r� ��
�
��m � '
a
��
'��.64�
N7g•�g�48��w
3
� �-
��
o �
� �
v •
ALMA R. EVANS o
72-E-82 rn
IS
�
r �
r �
�
�
w
�
a
V1
�
� � B 1084
„ .,.
PERSON COUNTY HEALTH DEPARTMENT �' -
WELL AND SEWACE �ITE, �.�CATION iMPROVEI���Ni' £'ERMIT
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 # _� ��
Owner/Contractor
LocationlAddress�
a,,�� '�auVice l e
Subdivision Name
33
��
Parcel #_ � �
Township � v � -
�/C ✓t S Date � //-� - �',��
7 -� SN �- /33 $' „ � � r <• x ; ,ri�� �P � ►� �
„_s � o ��; v��'e ►'o�-d b�c l�
Lot# �°� S.R„# �.`i
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area Size of Tank %�[7 Q ����ts
SFD Mobile Home Size of Pump Tank U c_�.�1
Business # of Bedrooms�_ Nitrification Line �(�U �) 3'
Max Depth Trenches a [ � �
Permits may be voided if site is altereci
Well and Septic Layout by (
Comrnents:
v
Date ���(X' �j� Installed by �„�...,.� �,,,; � Approved by
Well Perrnit Paid WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab
Public Replacement Air Vent
Site Approved Required Well Log
Well Head Approved Well Tag ,/
Grouting Approved
Comments:
Date
Installed by
Approved
This report is based in part on informatiun 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 specialict is also not
responsible for concealed conditions on the property or for statemen�s 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
satisfa�ctorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
.,
���:�;:�ur, cU11N'I'1' I•:NVI.1ZONh1k:N•rn�, iii.:ni,•i�i� ' � ` � �
, , ,. irl•,i.i. I,oc,
_ . - . ,��lle:��3e.�,� .
Owncz-: �----�1'-�s � 6�►-�
Locat�on/)Jixections: --- -/��m S� y �� . _ . �---._.__._� SR��
. . ----- -- - - .._
. _
....L:.':visioii N�ui��:: ------- •
. . ------ _.
D.rlllin T Conl���tc[i.�r: _ _. , . _ _ _ - -----�- LUL ��
� ��✓�t-,r � �l�// � // �
� _r�__ . _�_fL- �
wi;i_.r, cc�rv.Vr. rr
Dista��cc from Ncr►r��st 1'i�u�;�:� ty I.,i,i��_J.:.�_� c�,.s J�istallcu .Crolil Source of
Pollution o � �,,��
To�al Dep.[h: /��- f�t. :i icicl:____;% j? ��l'M ,Sc�itic,
.-._ ' • Watcr Lcvel
Watcr Bearing ,Lones: llc >�: � i� F[.
1_- �Q_ 1't- 1� t. Ft._�t.
Casing: 1�cpih: Fr�m �o "_. ---- -- �.i --- .---_. _
TYP.�: S tc 1 -- ��._ -- ---�5 .__ l.�i vi �c�cr: �� Inches
� -- _ C;alv;,tiizcd S[cc:l ..�
�If S[ccl, docs own�.�r :►��l,rc>v�;: l'c;; No _ .
wCl }I[:� � ' •-------- --------
S `I�,u�v,-_s:,:_`._ � �,..1-Ic��lz� Al�ovc Ground:-� jnches
Drivc Shoc: ycs No . •
Wcrc l'roblciiis �ii�.:otlntci-ccl i,i ,���«in�; [lic C:;�sinf;'? Xc�
� ., .. .
.It ycs �;ivc rcas�,:: -- �--_____
Grou[: Type: Nca[ ___—..;;:incl/Cc�iiic!-�t �-�---
-� Coricrcte � � •
Annular. Spacc,Wic;��,`--- 3_ ___ _. -_---rT��1���
Watcr in A.11nul.u- S�r.�cc: }'c:: No �___
Mct�lod: Pum �c:d 1`rc:�::u� � ` -- � -----
1 cs i��ccl ._._--
llcpth: ;rr�m ��;---------- ____ __ . .
Matcrials C1sccl; N��.litlLSl(�O(���) C�IIICII[ .
If mixturc (s;ind � -, - . `f Wcig,}it of.l bag �`lbs.
� ,�,i �vcl, cui.(in�,:;) �- 1Zat�o:------�. to 1
�ID 1 lates: Ycs �� No _.___ . ..
� 4 x 4 slab Ycs �—' No � . . . . ' �
__________._ I�IZILI,ING I.CX�
D -----
e--- ��_
F��m � To
D Z
.. .._ _� , __ I'oz-rnation Dcscri
. L�/_�,�___ -----�_________
7� `' �
.
- - - -�- _�f -- .� r a c.v .�_ �� . . _ �
— w �/�} c i� --�{=-�.r�._.1J_n_.1� ��
�^� � . -
tion
I HEREBY CER'TIF�' THAT..(.t_IE �,].;nVI� 1NFORM�1'I'lUN IS CORR
�� T�S WELL WAS CONSTR UCTLI� (N ,�,CCORI7,�I,NCL WI7'I-; E�'�D T]
FORZ'� �Y•Tr1E PEIZSON C�7UN'I'`r' I II;AI.TI-I Dl;pq}Z��'MENT REGULATIONS`'
__. . _ . � 4�P:1.."_r �L [-� .. . � � -
Sii;naturc: �f C'011lf:�ctc�r -� --�• �
Datc
II
.
'•`�r
:;:
- 'c
;:,.. �
r:F.�•
.��=.�i
: E��<-:
-..r.
''r :`:
;; s,,,� �:;
PERSON COUNTY HEALTH DEPARTMENT
SUBSURFACE WASTEWATER SYSTEM MONITORING REPORT
f Z2 l(
Date of Inspection
L:i'��.. ,
7 �6 4 � /�3r !�
System Ins llation Date Type Tax Map Parcel #
Address
Instructions: Check yes or no for appropriate items and explain in space provided for rerrarks and
comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate
by "N" and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance
and monitoring items specifiad in the permit are to be carried out.
INSPECTION RESULTS
COLLECTION SYSTEM:
Evidence of leaks ?
Tank risers accessible, free of
infiltration and surface water diverted ?
Septic tank needs pumping ?
Inches of solids:
Septic tank filter cleaned ?
EFFLLTENT DOSING SYSTEM:
Required pumps present & functional ?
High water alarm operating properly ?
Floats, valves, etc. in good condition ?
Control panel & components in good
condition ?
Effluent free of excess solids ?
Inches of solids(pump/dose tank):
Elapsed time readings ?
Counter readings ?
Drawdown rate:
DISPOSAL FIELD:
Evidence of effluent surfacing ?
Evidence of effluent ponding in trenches ?
Surface water effectively diverted ?
Diversions/swales properly maintained ?
Vegetative cover maintained ?
Protected from traffic/unauthorized uses ?
Distribution devices in good condition ?
Field free of settled or low areas ?
❑ � ❑
❑ � ❑
❑ � ❑
❑ � ❑
❑ � ❑
❑ � ❑
❑ � ❑
❑ / ❑
❑
❑
❑
❑
❑
❑
❑
❑
/
/
/
/
/
/
/
/
PRESSURE DISTRIBUTION SYSTEM:
Tumups/cleanouts/valves/taps intact &
accessible ? ❑ � ❑
Pressure head properly adjusted ? ❑ / ❑
COMPLIANCE:
Compliant
Non-compliant
Needs Maintenance
ADDITIONAL COMMENTS:
■
■
■
REMARKS