A37 9A ._ �
� Application Date: 3J � 7�
Amount Paid: �
RecEipt #: s2.
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APPLICATJON FOR SERVIC�S
Tax Map #: /� ' 3'7
ParcE� #: L�,7- �'`�/'
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PE32MIT IS INCORRECT. FALSIFiED,
CHANGED. OR THE SITE IS ALTERED. "ti�iEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALlD. -
1) Permit requested by: (Owner/agent/prospective owner): a Lv�
Home Phone: � - o `—' Address: �� ��� –
Business Phane: �7 -�,�'�� �'�./�o�t-m �c 2�s-?�
2) Name and address of current wner. ��n1i c� �- • 1`(%�.
�. �
/,�DlG�a GL'L 2'I S a
3) Property Description: Lot size: 3�5`�`'"�Township: `�02� Subdivision: .,�ir. �-� Lot# 1
Directions to the property (Including road names and numbers): l►�u..c: �-i s�.-rno�r.� �.��,� �,.� ,��_
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C.u.2tl�� �1G� StfIR-t�lf-t—/�1� -►JG'�l��.n.ytry,.t�-vYi� -r'i2.id-c�[�t.�%zc�./ls.l, i3/2/<L� �%D�.oN
t�+-tJ �l��f-N /��— E.'�cJ OrF Qa.'1�4-0 .
4) proposed Use and Structur� De��ription: answer each of the following questions:
a) Proposed _, Exis6ng �, Type of Structure: Width: Depth:
b) Ivumber af Bedrooms: 3 Number of occupants or people to be served: �–� �
c) Basement: Yes �. No _ Will there be plumbing in the basement? .�
d) 6arbage Disposal: Yes , No ,�
5) Water Supply Typ . Private new ,_ or existing�, Public� Community� , Spring _
Are any adjoining property? Yes_ No ✓�If yes, please indicate approximate location on the
�site plan.
6) Does your property contain previously identified jurisdictional wetlands? Yes_ ��
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKEDa �,
➢ THE PROPOSED LOCATiON OF ALL STR�a�TURES MUST BE STAFCED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF.
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 piaced on the property. I understand if the site is altered or the intended use changes, the permit shall
become inv '
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Owner or Legal Representative Date
PCND, tev. 06127102
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WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map 3� arcel # � Township:
Applicant: c� ��� �v� �S � o � l�b rn.c
Subdivision: �w � � Lot #
Location:
Type of Water Supply: � Individual _ Community
Requirements:
Site Approved By: �
Grouting Approv By: � -� '� �
Well Log:
Pump Tag:
Well Tag:
Air Vent: �
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller: �,U �
Well Approved by:
****See Attached Site Sketch****
Public
Liner:
Installed by: :
Depth set: _
Grouted:
Date:
Water Sample:
,�1
Wells must be 10 feet from property lines. .
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
Date: ,
PCHD rev O1/27/04
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..:son i:o Cnc;��,�nan'.ai Nea!:h J:S659.'?BGS ..�
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Owner: `� d• Tax ��ap,� 3 9 Patcei #�_
Location: a :�
Subdivision, � L�t # ��
��'eI� �orostruction
I?istance From nearest Property Line ('_��inunum 10 feet) �
DistAnce from Septic System (R�iinimuffi 60 feet) T—�
Total Depth: � ft Yield: GPM Sta.tic Water Level: _�_ ft
'Water He�ring 'Lo�es: Depth ft ft _ � ft ft
C�asin�:
Depth: Frorn � to __,� ft. Diam�,�t�r: re i, in
Tyg$: Galvanized Steel r� �
Weight: f 3 Thic�ess: _!8'� Hei�ht a�ove Ground: �� in
Drive Shae: Yes I�o Any problzms encountereti while setting casing? Yes _No
If "yes" give reason:
Grout:
Neat: Sand/Cegnent � Concrete Gz�veUCement
Annular Space Width inches Water in Annular Spuce '� .- `es T C�6
Method of Grout: Pumped Pressure Poured r/ Depth to Ft.
Materials Used:
No. Bags Portland cement Wei�ht of 1 f ag
If mixture (sand, gravel, cuttings) - Ratio _� ta
ID plates: _�es _ Nn 4 x 4 slab �`i'es _
Gl � Pounds
Na
Driliing L�g Locatiun Draw��
I hereby certify that +he above info*rnation is conect and that tbis w�;ll was cas�strr.?cted in a.ccordance� urith regulations
set forth by the Persan Cotu�ty Health Department.
Signaiure of Contractor YD �,�03 � Bate ,�- -� ' �`�
PCF� rev O1l1bi02