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A40 18Anplication Date: r 0 l� � r Amount Paid• � Receipt #: �Q� �� Person County Heaith Department Environmentai Health Section APPLICATION FOR SERVICES Tax Ma #: �O Parcel #: l 1C �� e�� d D �` �a,� IF THE 1NFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED CHANGED OR THE SITE IS ALTERED, THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. 1) Permit requested by: (Owner/agenUprospective owner): � io ('� t�I �� Home Phone: �!�- �y�i2 Address: al : Srr�c� s'��r� Business Phone: ^ ��y��,�,� r�ic a�„�jj� T-'^ 2) Name and address of current owner: `�'�� 3) Property Description: �ot size: Directions to the propertv (Incli road names and 4) Proposed Use and Structure Description: answer each of the following questions: a) Proposed 0, Existing ❑ � b) Stick Built �, Modular ❑, Single Wde 0, Double Wide ❑ � c) Number of Bedrooms: d) Number of occupa o e to`b rve :� e) Basement: Yes ❑, No ❑ If yes, # of basement fixtures: � �, ' � Garbage Dtsposal: Yes ❑, No ❑ g) Dimensions of Proposed Structure: Width: Depth: 5) Water Supply Type: Private �(new � or existing ❑), Public 0, Community C�, Spring ❑ . Are any wells on adjoining property? Yes � No � If yes, location 6) Please Indicate Desired System Type: (systems can be ranked in order of your preference) _Canventionai _Modifled Conventional _ Alternative _Innovative Other (specify): CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY. STAKE THE CORNERS OF ALL PROPOSED STRUCTURES. PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION Fo[[o� � � � 2Y � O `� � 'jt �r'''� se� �. Q� ��-Y 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 placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand that as applicant, I am responsible for identifying and marking property lines, comers and making the site accessible for the personnel of the Person County Health Department to conduct their evaluations. I understand that I am responsible for notifying the Health Department if my property contains any wetlands as designated by the Army Corps of Engineers. 16 -l�-0 wner or Legal Representative Date PCHD, rev. 10/12/99 PERSON COUNTY ENVIRONMENTAL HEALTH PLEASE SEE ATTACHED PLAN FOR WELL StTE LAYOUT ��p �� . Tax AAap �: Q Township ��Q� /�' i ve r ZoNng . �►PPilcant �1•t.i1( (7r t�11� � . �o�: �°II ?�ne..s St��e �� P . �y 8�etlon• LoC Subdlvfsion: r / Tvpe of Water Suupiv: Reauirements• Well Permit ' �ndividuat Community Public Site Approved y t/�3�`m G�t« �� In �s-oi Grouting A p vetl by ' �� Well Log Well Tag Air Vent Hose Bib - Concrete Slab Weli Drilfer: Welt Approved By: � Date• **See Attached Site Sketch** WeUs must be '10 feet from property fines. Welis.must be 100 feet from septic systems. � Wells must be �at least 25 feet from any buifding foundation. conditions: �ee �d r�,��n5 �F. S;tt S�K ��EG�' �ther . PCHD, rev. 11/29/99 0 Appiication #: Tau Map #: 1�'�� Parce! #: ►'� Person County Health Department Environmental Health Section k � _. U�'1 l 1r� �(\ V �� Applica t's Name ��f, '� �L� Authorized State Agent SITE SKETCH �' / f� Subdivision/Section/Lot# �� :.��5 -C�I Date System components represent approximare contours only. The contractor must flag the system prior to beginning the installation to insure that proper grade is maintained �� --�� ES ;joP� '� - �� , � . �amH �e l l IDc�1�``�� , �'cc � � 5 �� by �' - +� �� ;� �, �..h � �-� �c J ..�,I� � �� n� a ._ �rv q,i, �F C�S'�0 �� yy , °�' .� �� ,i 1�c. ll �� ; ��= Scale: (�`� �`" � �� If1.S Gl.fre r'rlui ��C_ut-�� I t 1 t� � i l r� t�t b�- � r�v�tc.d � � t PC�1D, rev. 9Q/12/99 � Date: Owne Locat PERSON COUNTY ENVIRONMENTAL HEALTH WELL LOG Subdivision Name: __ Drilling Contractor: � � Lot # WELL CONSTRUCTION Q Distance from Nearest Properry Line 1 c) Distance from Source of Pollution t G a �, Total Dep.th:� ( F� Yield: GPM Static Water Level a?.S—' Ft. Water Bearing Zones: Depth �_F[. � F[. F� Ft. Casing: Depth: From 6 to ?� Ft. Diameter: Inches TYPE: Steel - Galvanized Steel If S teel, does owner approve: Y�s No � Weight: Thickness:� '� Height�Above Ground: /�/ Inches Drive Shoe: Yes ✓ No . Were Problems Encountered in Setting the Casing? Yes No � If "yes" give reason: Grout: Type: Neat Sand/Cement / Concrete Annular Space Width � Inches Water in Annular Space: Yes No _ .. Method: Pumped � - Pr:ssure � Poured � - � Depth: From O to � O Ft. Materials Used: No. Bags Portland Cement Weight of .l 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 INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY�THE PERSO�t C^vui�TY HEALTH DEPARTMENT. . , _ � -- i naturc of Contractor D� tc � „ � H O a � w U � a L� • ' M Improvements Permit (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing) Improvements Permit (Unrecorded Lot) Repair/Replace existing Septic System Improvements Permit (Mobile Home Replace) Permit for New Well Improvements Permit (Addition) _ Replace Existing Well _ Bacteria � _ Chemical � _ Petroleum I Pesticide � _ Lead 1. Permit requested by: Dimensions or Proposed Structure: owner/prospective owner/agent: � � � idth: / `f ddress: ,i� /.3�f�_�S � Depth: 7� 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? or�e Phone #: 3!�-��'I j�' � usiness Phone #: . Name and address of current owner: 9. Water supply ty�pe: private ❑ public ❑ community ❑ sprir►g 0� Are any wells on adjoining property?Yes ❑ No ❑ If so, identify location: 3. Property Description: Lot size: . Tax Map#:� `fd 10. Type of structure/facility: Proposed: �Existing: ❑ Parcel#: � 5� Type of dwelling: Township: House: ❑ Mobile Home: C�'�siness: 0. � 5. Directions to property: State Road #& Road Type of business: � ames, etc. Number of Employees: S � n S,¢ o �e � Number of bedrooms: a �y � b� Garbage Disposal? Yes ❑ No Ga'� F' Basement? Yes ❑ No If so, # of basement fixtures: I6. Number of occupants or people to be served: a- CLEARLY STAKE ALL CORNERS OF THE PROPERTY ANll '1'tl� C;UKIVL�'KJ Ur� ALL PROPOSED STRUCTURES. 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 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 site by the Health Dept., this application shall become void and all fees paid forfeited. T z �igned Owner o�i�horized Agent .�` � . ,:i Permit Is�ued'❑ Signature Date ` ' Permit Denied ❑ Plat Observed ❑ FACTnRS-STi`BEVALUA27L?N ARP1Y1 AREA2 ::: i1REe13 ' AREAd :: __ ._ . _.: 1. SLOPE ( k) S S S S PS PS PS PS U U U U 2. SOIL IEXTURE (12-36 IN.) S S S S (SANDY, LOAMY, CLAYEY. N07E 2:1 CLAI� PS PS PS PS U U U U 3. SOIL STRUCIURE (12-36IN.) S S S S (CLAYEY SOILS) PS PS PS PS U U U U 4. SOIL DEPII-I (IN.) S S S S PS PS PS PS U U U U 5. RESTRICiIVEHOAIZONS(IN.) S S S S (Rv1PERV10US SiRATA. ROCK) PS PS PS PS U U U U 6. SOIL DRAINAG&GROUNDWATER S S S S (EXTERNAL & INTERNAI.) PS PS PS PS u u u u 7. SOIL PERHtEAB(L1TY 5 S S S (PERCOLOATiON RATE) PS PS PS PS U U U U &. AVAILABLE SPACE S S S S PS PS PS PS U U U U 9. SIIECLASSiFICATION(SEEBELOW) SOIL SERIES S-SUITABLE PS-PROVISIONALLY SUTfABLE U-UNSUITABLE RECOMMENDATIONS/COMMENTS: SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope patterns, etc.) C:ViMIPRO�DOCSIAPPSEC.SMFINANCE.PC w � . �z� �q 0425 PERSON COUNTY HEALTH DEPARTMENT � • WELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT PERNIIT Tax Map # F} 'f D Parcel # !� 7,oning Township r Owner/Contractor �-irho� �x� A '�� Date a Location/Addr s�}u��►S,%�(` orl Snnes �o� R�__ 1 Maf�) �c° !-�an�e o� I � S.R.# ' Subdivision Name Lot# I.ayout � f�f rv�+-�' VJr �-�'iER "t'� v--� �D vJ New Mo6� I e t-�ome a I�d�a�s -+o re� I�ce o �d � b�'d��.►-, Mc� �� e f-%/�'� W i`I'� 1�1�a G�al� e5 '�o �X-�5��n ��G .�y �'M �J � As Installed � SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area /% f}��2 Size of Tank �x;.y¢-;.�,c� SFD Mobile Home ✓ Size of Pump Tank Rusiness # cf Bedrooms o'� Nitrification Line �'�ci�-ii� " ' Max Depth Trenches � ' Pernut Void after 60 months. Pernut Void if not in compliance with zoning regulations. Pernuts may be voided if s Well and Septic Layout by Comments: ,_ Date Ynstalled by �n �L � Approved by `' �, � . idividua ublic ite �prc � Head ' �uting E i /. . /Semi �,ECIFIC TIONS Requir .d Slab � Air ent Re uired We o� ell Tag Date I stalled � This r R is b d in part o informatio rovided the ho eowner or s/her repr ntativ� environmental alth speci ist is not res onsible for fals or mislead' g informati contau is also not res nsible for �ncealed c ditions on the operty or f statements this repc statemznts provided to in the ap ication. Neith Pecson County nor the dvonmenta continue to function satisfactorily in the future ot that the water supply will temain potable. ORIGINAL �prov by _ in application su mitted for this mu� The the applicatio The enviro tal health specialist ,that may have resulted from fals or misleading health specialist wazrants that septic tank systetn will c:�amipro�permitsam O1/95 rev.1.0