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Improvements Permit. (EstablishedlRecorded Lot) _. Reinspection of Existing System (Loan Closin
� Imt�ovements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) _ Permit for New Well
Improvements Permit (Addition) _ Replace Existing Weil
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Bacteria Chemical Petroleum _ Pesticide _ Lead
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1. Permit re b:. �� M� =.t'
owne os ective owner gent:
Address: � t��o✓ L r�-
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Home Phone #: I�I – % k -3
�Business Phone #: s'�9 - 3/ f 3
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and address of current
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Description: Lot size:
p��7. Dimensions or Proposed S[ructure:
Width: ��
Depth: / � __
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?
�� .�....�_�",�.�.�'�'—i,� �lQx /G /�!e �1�taaN
9. Water supply type:
�. private �.. public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes � No �
�,_ If so, identify location: � M 61 v�
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, Tax Map#: /`t . -5 6 `�"'
Parcel#:
Township• � o.o�s u.1L�
. Directions to property: State Road #& Road
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10. Type of structure/facility: Proposed: (�xisting: �
Type of dwelling:
House: ❑ Mobile Home: L� Business: ❑
,Type of business:
Number of Employees:
umber of bedrooms: �_
Garbage Disposal? Yes I'� No C�
Basement? Yes ❑ No�f so, # of basement fixtures:
�Num�ec of"occupants or p`eople to be served: y � �
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 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 [he property to [he 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 shal come void and all fees paid forfeited.
Sf�nc3 Owner or Aulhorized
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B 2386
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 # ,q' � � Parcel # �
Zoning Township ,�� Sl'�/�, f �
Owner/Contractor �aM � , �, � n q. Date � - / / � Q
Location/Address
1 � �0.�r,�
Subdivision Name
rt
Lot#
S.R.#
SEWAGE SYSTEM SPECIFICATION5
Repair Lot Area Size of Tank IpODG�-�
SFD �� Mobile Home Size of Pump Tank
Business # of Bedrooms � Nitrification Line �7a ' X3 !
Max Depth Trenches a �l "
Permits may be voided if site is Itered or intended use changed.
Well and Septic Layout by
Comments: 5
Date In lled b Approved(I
Well Permit Paid WELL SYSTEM 5PE�IFICATIONS
Individual t/ Semi-Public_
Public Replacement
Site Approved
Well Head Approved
,,. . . ..., _ .
Comments:
Required Slab lc� l
Air Vent
Required Well �
Well Tag
Date Installed by �;r (IP`�}-�, Approved by.
�i
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
contai�ed 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:\amiprolpermit.sam O1/95 rev.l.l
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PERSON COUNTY ENVIRONMEHTAL HEALTH '
WELL LOG
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Date: ' � •
Owner: _� 3�r-t A. -, . �
Location/Duect�ons: o� � T SR#
Tt. � , �� 'C'�., ,� � � ,. . ..,.�t.....�_ � � i�T �_.._ —. _ i
Subdivision NZrne: ____ Lot #
Drilling Contractor:`�a�a,�..tETE L�F,1 L��-r� t-r► r�
WELL CONSTRUCTION
Distance from Nearest Properry Line_�p • Distance from Source of
Pollution_ l 00 '
Total DePth:�__ �'t. Yield:_��j______ GpM Static Water Level
-�__I=t_
Water $earing Zones: Depth��__Ft.t-z-a-��' FL�F�.�-�o�t.
Casing: Depth: From O to�_Ft. Diameter:�'I� _��}��;
TYPE: Steel � Galvanized Steel /
If Steel, does owner app:ove: Yes No
Weight: Thickness: . t Height�Above Ground: Iy Inches
Drive Shoe: Yes � No
Were Froblems Encountered in Setting the Casing? Yes No_�
I[ "yes" give r�ason:
Grout: Type: Neat Sand/Cement Concrete
Aruiular.Space Width Inches
Water in Annular Space: Yes No
_ .. Method: Pumped . - Pressure � Poured_��. � � �. _ .
Depth: From_ o co- Z.Q_Ft. . .
Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs.
If mixture (Sand, gravel; cuttinos) - Ratio: to
�ID Plates: Yes � No � � :. �
�� 4 x 4 slab Yes � No �
I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSOv C�'vi1`I'Y HEALTH DEPARTMENT.
ignaturc of Contractor Date
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