A40 17�v
'�P.mou't�t paid ���� � �,:�G� � �
R�ceipt 1i � �Q Date
. a i^
1, permi[ requested by: . . 7. Dimensions or Proposed Scruc[ure: �
owner/prospective owner/agent: -.� Width: � � X� Q
_ . T__�L.
�
�
w
U
�
a
Home Phone #:_
Business Phone #:
W
�
z
���'e � 8. What type (if any, additions, expansions, or
ls' replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
Name and address of current owner: 9. Water su ply t}•pe:
� b�� ` p N dr � i � private public ❑ community ❑ spring ❑
� Are any wells on adjoining property?Yes ❑ No Q
If so, identify location:
Property Description: Lot size:
Tax Map#: �k 9'O
Parcel#: 1� �
Township: 1= � a..� '�� � e-�'
Directions to property: State Road #& Road
imes,�tc.
� 1 1�.o�,.S2 a ►.3 C12
01J �ON eS S
10. Type of structurelfacility: Proposed: �xisting: Q
Type of dwelling: � X �Sa-i �
House: �Mobile Home: ❑ siness: ❑
Type of business:
Number of Employees:
Number of bedrooms: �
Garbage Disposal? Yes C] No �
Basement? Yes❑ No��so, # of basement fixtures:
�6 Number of occupants or people [o be served� 3� '
CLEARI;Y STAKE ALL CORNERS OF TT3E PROPERTY AND THE C4RI�IERS �F ALL
PROPOSED STRUCTURES•
I hereby make application to the PerSOri C011nty Health Deparfinent for a site evaluation for the on-si[e
sewage disposal system for the above described property. I agree that the con[ents 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 ctianges, the permit shall become invalid. I understand that before an Improvemencs Permit can t��
issued, I must present a survey plat of the property to the Health DepG I understand that in the event I have no�
delivered a survey plat of the propecty to�the Health Dept. wi�kiin 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become vott3 and all fee"s paid forfeited.
� �v� �.�.� ��1'��
Signc3 Owner or Authorized Agent
��
Permit issued ❑
permit Denied ❑
Plat Observed ❑
Signature
, .
Date
.
x;F'r�`s�j`tr� �'�:^'' �I�CfOR�SNEEVALUJ171(� ;'x%teE�" ityyC Ayil�r'�,�zy�i5a ,rr,� Ak� �> ^C' *�'R�`+1���3 a�e4 ''��{Z'.E�y��.�^� Y �
akweq7t,L�� . . ..r:krs « .......: ., ... .. . . ........ _�.�i w?�. ; 9.'2;-- ,�'r.�.+- � isYi.sYZii�ZA:��r?7 ,'�' 'St,» .'� �i»'F "A.'k hf�. �. :�2.�1....',t't� ��i 'lilSda:L.•:. `.o.! � �. �i�St.ax
�r
1. SIAPE (A) S S S S
PS PS PS PS
U U U U
2. SOD.I'F7CTVRE(12•)61N.) • S S , S S
(SATIDY, COAMY. MYEY. NOTE 2: t Ml� PS PS PS PS �
� U U � U U '
1. SOTLSiRUCTURE(I2•361N.) S S S S '
(C1JIYEY SOR.S7 PS PS PS PS -
U U U • U ,
4. SOILDFp7ii (W.) S S S S
PS ' PS K PS
U U U U
S. RES7RICJ1VE2iORRANS(IT7J S S S • S•
(IMPERVlOUS SiRATA. ROC1C) PS PS PS PS
u v u u
6, soILDRAtNAGFJGROVNDw/l7ER S 5 s s
c�nrru a wrFxx�w es ' rs rs rs
u • u v u
�• sou.�.s�snm s s s s
crFxcbt.oAnox w►� rs rs es rs
- . u u u v
E. AVAIIJIBLESPACE S S S S,
� PS tS PS
' ' U U U U
9. SRECI.ATSiF7GT10N(SEEBELO�
SOII.SERJF,g • . '
�
SSUITAIILE tSiA0YK70NALLYSt)I7AIILE IAtA+SUifAELZ
RECOMMENDATIONS/COMMENTS: '
SI1� CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns� CtC.� . C:MMfPRO�DOCMPPSEC.Sr1 FW�NCEPC
��1 � LL t��" ��`'� ���� A 0 01 1 7 7
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlvIPROVEMENT PERMIT
Tax Map # � yo Parcel # / �
Zoning ' _ _ ... •`Township �=c�Tf2� vcF'�.
Owner/Contractor Bc. TT'� 1� i c I� r'1 A N Date � s�
Location/Address N w Y i s-� �'� `^"' �� i�4� R-D`� r"'' `� � / Z
, J"��ec s ST�.�� � �. /-= ��S c � �� �,y S.R.# // `j'� �
�
�
�
U
�
cd
a
Subdivision Naine Lot#:
, , � SEWAGE SYSTEM SPECIFICATIONS
Repair : L� Area / �ize of T�ank
SFD :':��bile Hom� - Size o�Pump T
Business /# of Bedrooms Nitn jfxcation Li�
� Max Depth T,fe
Permit Void after 60 months. Permit Voiii if not iri compliance with zoning regulations.
Permits may be voided if site is alt ed r intended use changed. �
Well a�rn3'S� Layout by �� � ��
Comments: � Q � c-� �c= Pc•4 c r-� �� �r � ���- . �l�D �r����
�E-+a� �D �3E A13ANi»NJ��
Date Installed by Approved by
WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab
Public � Replacement Air Vent
Site Approved �� Required Well Lo� ��
Well Head Approved Well Tag
Grouting Approved � q rl
Comments:
Date 7/�919'7 Installed by�p�, (�.�'n �f � Approved by
This report is based in part on information provided the homeowner or his/her representative in the application submitted for tivs pemut The
environmental health specialist is not responsible for false or misleading infoRnation comained in the application The environmental heatth 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 Pecson Courity nor the environmental health specialist wazrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:4vnipro�permit.sam O 1/95 rev.1.0
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date: �a Y - '
Owner: � ,e,�
Location/Directions:
1 Y' �-� �
Subdivision �N�une:
Drilling Contractor:.
_ SR#
Lot #
. WELL CONSTRUCTIOI�
Distance from Nearest Property Line /U Distance from Source of
Pollution /CX� '
Total Depth:�_ Ft. Yield:� GPM Static Water Level a__Ft.
Water Bearing Zones: Depth �_Ft. �t � Ft� F�, �t
Casing: Depth: From C� to,�' _Ft. Diameter: �' Inches
TYPE: Steel - Galvanized Steel ✓'
If Steel, does owner approve: Yes No
� Weight: � Thickness: /� HeighrAbove Ground: / Y Inches
Drive Shoe: Yes � No
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" give r�ason:
Grout: Type: Neat Sand/Cement � Concrete
A.nnular. Space Width Inches
Water in Aruiular Space: Yes No.
_ .. Method: Pumped . ._ . �Pr:ssure � � � Roured .� .._ . . . •, - :
Depth: From d to ao Fc, � �
Materials 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 INFbRM�1TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH �y�THE PERSON C�Ui�iTY HEALTH DEP RTMENT.
� ignature of Contractor Datc
►..