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Permit� (Established/Recorded Lot)
Impxovements Permit (Unrecorded Lot)
improvements Permit (Mobile Home Replace)
Improvements Permi[ (Addition)
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of Existing System (Loan Closing)
_ RepaidReplace existing Septic System
it for New Well
Existing Well
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Bacteria Chemical Petroleum Pesticide _ Lead
_ �.,l,o,.-i- Davis
. Permit requested by: . � 7. Dimensions or Proposed Structure:
wner/prospective owner/agen� -� .�-� Width: �
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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 #:� S i%' z���d
usiness Phone #:.,�/9� �?�l � 3J gy
Name and addre�s of current w er: /�-?l 9. Water supply tyge:
�,�,,,� - �yf ! ` G �, private f�public ❑ community ❑ spring ❑
q�„�o,,,�� �r.� z; ��� 3 Are any wells on adjoining property?Yes ❑ No [�.
If so, identify location:
. Lot size: -� �
Tax Map#:
Parcel#: _
. Directions to property: State Road #& Road
iames;�tc. � �/D D /1 � I
,�estA__�. �A// __.�
Number of occupants or people to be served: -3
. ype of structure/facility: Proposed: (�Existing: Q
I'ype of dwelling:
House: ❑ Mobile Home:� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �_
Garbage Disposal? Yes ❑ No �
Basement? Yes❑ No�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 Depal'tment 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 si[e by the Health Dept., this application shall become void and all fees paid forfeited.
s�
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Owner or Authorized Agent
0
Permit Issued ❑ Signature
Permit Denied ❑
Plat Observed ❑
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Date
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.) C:1AM[PRO'�DOCSAPPSEC.SM FWANCEPC
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PERSON COUN�I'Y HEALTH DEPARTMENT ►
WELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT PERNIIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shatl be issued until Authorization for waste water system construction
has been issued.
Tax Map # � ,� �
Owner/Contractor
Location/Address
Name
Parcel #
Township I.J � o s e
> Q v i S Date s��� f ,
r1' /Jri'r.:.�1e 1—oa/ �„ hf i��.st D%cr TT%%✓nGeas
.R.# /33 '7
Lot#
SEWAGE SYSTEM SPECIFICATIONS
_ Lot Area , �cv� Size of Tank /����
Mobile Home Size of Pump Tank ��
# of Bedrooms � Nitrification Line ��D ��3 �
� n. .,, �e ,� � ,/_ .._ Max Denth Trenches ��' « _
(/ � b n ��
Permits may be voided if site is altere
Well and Septic Layout by
..� . t
Comments:
Date (,,o)a -9-� Installed by
chan
Approved by
ell Permit Paid L� WELL SYSTEM SPECIFICATIQNS
ridual Semi-Public Required Slab �
ic Replacement Air Vent ✓
Approved ✓ Required Well Log
Head Approved Well Tag I�
iting Approved ✓
Comments:
s��
---- - —r-- - -- ----_-- -- r--- - -- ----------- r- -
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:lamipro\permit.sam 01/95 rev.l.l
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Building Additions/ Mobile Home Replacements
Tax Map #: �o'?�s
Approval Requested for:
Applicant
Address:
Phone #'s:
Parcel#: ►� Z
�Z
Mobile Home Replacement
�_ Building Addition CC�µ�.�, �- � x -�lRo '
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Permit Located: ✓ Yes No
Installation Date: / q Q7 Design flow: ��D (gpd)
Current Contract with Certified Operator on file (if required): �
Water Supply: ✓ Well Public or Community
Wastewater system shows no visual evidence of failure on:
(Applicant's signature if site visit is not required)
(date)
Addition/Replacement Approved
Environmental e th ecialist
11/15/OS
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Date
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Date: � '� -9 '
Owner: � �
Location/Directions:
Subdivision Name:
Drilling Contractor:
PERSON COUNTY ENVIRONMENTAL HEALTH
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WELL LOG �
SR# �33 � ' � .
, ii� .� � . _ �--- : r .
llistance from Nearest Properry Line ff� ' Distance from Source of
Pollution f.��_ ''
Total Dep.th:� ,�r� Ft. Yield: �C� GPM Static Water Level aS— Ft.
Water Bearing Zones: Depth 97 .F[.�7J Fc. o? 9O Fc. �t.
Casing: Depth: From�_to�Ft. Diameter: ��, '�, Inches
TYPE: Steel - Galvanized Steel �
If Steel, does owner approve: Y�s No
� Weight: � Thickness: !�� Height Above Ground: /�( Inches
Drive Shoe: Yes � No
Were Problems Encoumtered 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
_ . Method: Pumped . Pr:ssure Poured .� . . . . _ _
Depth: From C'i ;.o a� 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
I HEREBY CERTIFY THAT THE ABOVE INFORM�ITION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED lN ACCORDANCE WITH REGULATIONS SET
FORTH �3Y�THE PERS0�1 C^vui1TY HEALTH DEPARTMENT.
Signature of Contractor Datc
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