A36 17s
, Ar�oun t
r. Receipt
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paid a J�,
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1-�-�q
Date
Y_ -
Improvements Pecmit. (Established/Recorded Lot) _ Reinspection of Existing Sys[em (Loan CIosing)
ImpFovements Permit (Unrecorded Lot)
lmprovemencs Permit (Mobile Home Replace)
Improvements Permit (Addition)
Repair/Replace existing Septic System
Permit for New Well
__ Replace Existing Well
,�Permit requested by: . 7. Dimensions or Proposed S[ructure:
owner/pros ective ownedagent: i �-� .' Width: �8
Ad ss: � <� ��, � ���� Depth: �
�axb0'2�' �C Z� 1 8. What type (if any, additions, expansions, or
�
� - replacement is anticipated to the structure or facility
W � 1 that this sewage disposal system is intended to serve?
,v�, Home Phone #: -'�!'�-� - � ,.�� �
�¢ usiness Phone #: _ /�
}C !
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and address of:current owner T,�� 9 Water supply type:
�_-'i�c�hlra ���'�i � rivate ✓�. public ❑ community ❑ spring ❑ ,
337'7, ' Are any wells an adjoining property?Yes ❑ No �.
;r�t� n:�C.- 7�75 73 �If so, identify location:
3. Property Description: Lot size: o(. A-C_
. Tax Map#:
Parcel#: � �'
Township: _�.�rr.�nr��^,;�Y�..
�
a�. 5. Directions to property: State Road #& Road
ames,�tc. t e
� t .�n ��.�� ��t �o a331. �� ���!¢_��� ` � �
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1�Type of structure/facility: Proposed: ❑Existing: Q
Type of dwelling;---_—� �/
House: Q Mobile H___ om�c �l Business: ❑
Type of business:
Number of Employees:
�i Number of bedrooms: -3
,,n �'rarbage Disposal? Yes ❑ No [�
Basement? Yes ❑ No�''If so, # of basement fixtures:
�6. Number of occupants or people to be served: _�� 1
) CLEARLY STAKE ALL CORNERS OF'?'HE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PeI'SOn COunty Health Department for a site evaluation for the on-site
se�vage disposal system for the above described property. I agree that the contents o: th:s application are true
and represent the maximum facilities to be placed on [he 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 mvst present a survey plat of the prope�ty to the Health Dept. I understand that in the event I have nat
delivered a survey plat of the proper[y [o the Health Dept. within 60 DAYS after the date oE the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
�
Signce� Owner or Authorized Agent
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* PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
l�;ot 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 � Parcel # %
Zoning Township `
Own Contractor ' Da e —���'i
Location/Address .s"� $ 73:� 6�-s l�� 1�3 �
� �z. %�, ��".�., P S.R.# t 3 x 6��33 �I
Subdivision Name
Lot#
SEWAGE SYSTEM SPECIFICATIONS
�ir Lot Area Size of Tank �� "� �
� Mobile Home Size of Pump Tank%r�'
ness # of Bedrooms � Nitrification Line �OD ` �C;� l
Max Depth Trenches�'�,��2���Z�t
Permits may be voided if site is altered or intended use changed.
Well and Septic Layout by .,t��.�
Comments: �.�
�� / Public �
q� ite Appro
��� Well Head
Grouting �
Comments:
Date 3-�-�Q Installed by.
� . �
c�,�., � � 3-�
z -��
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
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 O1/95 rev.l.l
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PERSON COUNTY ENVIROIQMENTAL HEALTH
WELL LOG
. ._• • . '. _ . . _ J �..'�n•.�
_ ' �.
� , . , , . � •.
Daie' � . . .
- -�-- . � __ _ - -
Owner. �G �u or�-i a.s SR# ' � �
Loc,ation/Duections: -�-�wF ��u��, aw � �,�cl. -r► � : . r
-r�_ "- - . _ ��--�_
Subdivision Name:
Drilling Contractor:
WELL CONSTRU
Lot #
Distance from Nearest Property Line io Distance from Source of
Pollution (.oc� `
Total Dep.th:_ t8o Ft. Yield: 5 GPM Static Water Level_ z.s Ft.
Water Bearing Zones: Depth �,�t.-�u' �F� � Fc. ��
Casing: Depth: From�_to�_Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel 1
If Steel, does owner approve: Y�s No
� Weight: � Thickness: IF� HeightAbove Ground: <�� Inches
Drive Shoe: Yes ✓ No
Were Problems Encountered in Setting the Casing? Yes No ,�'
If "yes" gir•e reason:
Grout: Type: Neat Sand/Cemen[_ ,/ Concrete
Annular.Space Width Inches
Water in Annular Space: Yes No
_ ._ Method: Pumped . . �Pr:ssure � � Poured ✓ ��' �- � � • •. - :.
Depth: From O to_ �. � Ft. . .
M � __
atenals Used: No. Bags Portland Cement Weight of .1 bag_lbs.
If mixtuie (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes ✓ No � � � •-" .
4 x 4 slab Yes—�—No �
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C�UidTY HEALTH DEPARTMENT. �
✓ ---
�Signature o� Concractor atc
�i