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A40 116AoQitcallon Date: �� .�mount �aid: � R� ��81� C�G(o� � � �~�� .TN � - �C �L' �' ��..��-.m�... _,_.. __,_.. �.a �r��s��. APPl.1CA7lON F-0R SdilliCeS TaxflAau #- � V Parca �: 'IF T'HE INFORMATION IN THE �,PPl:lCAT10N FOR AN IMPRO�ENT PERMtT iS� INCORRE�'. F�4LSIF�ED. C!-iANGED, aR THE SI'TE 15 ALTERED. TliE3V THE IAAPROVEiUIENT PERMR AND AUT'HORIZ�►'iION TO . CON3TRt1CT SHALL BECDafE INVALID. -• 1j Permit requested by: (OMm ' �.�Prospective cwne�: � Home Phone: ` " � �'�5 Address: � Business Phone: 3. 5 _ ` . . . .. _ _ . - �i o ��• �s � i � , , , _ ,' = . 'f��''• , �•� 3j Pcoperty Description: Lat size: � Tawnshlp: Dtc�fians fio the property pndudinA raad names-an.d #�� 4) Propcs�d Use and Stnacture Description: answer eac� the fallowing questions: a) Proposed �,/Existing , Type flf Structure: �a�/,S'G Width: � Qe�th: b) Numbec of Bedrooms: _� Num6er of accupants or peoQie to be� served: �� - c) Basement Yes . No �/WW there be plumbing in the•l�asement? n/fL d) lSarbage �isposal: Yes � . No / . 3� wa�'SuPP�7�'�e: Privafie �new;�orexisting ). Publig . Commw�iiy� , Sp�ing � . Are ar�y wells o� adjaining property? Yes No �(f yes, piease ind(cate ap�ximat+e locatiori on the .site pian. • 6} Does your propariy c�ntain_previously ide�iiied �urisdictional vr�lands� Yes_ No � PLEASE NOTE THE FOLLOUYING• ➢ A PlAT OF THE PROPEiZTY OR S1TE PIAN QAUST PiE SUHMITTE� WlTH 'T6�ilS �PPUCATION. ➢ PROP'ERTY UNES AAI� CORNERS NUST BE CtEARLY BAARI�. •, 9 THE PRaP03ED LflC�T10N OF ALi. STRUCTURES MtJST BE STAi� OR FZAGGEi). ➢ THE SITE RAUST BE RF�DILY ACCESSiBI.S F�R AN EVALUATION BY THE HEl�►Liii DEPARTME�IT S'i'AF'F. . I here�y make application ta the Person Caurrty Health Departrnent fnc a siie e�aluatIon fior the on-site sewage disposal system for the abav�described property. 1 agree that the corrtents of this appiicatfon are true and represent the maximum facili�es to be placed an the property. I undetstand ifi the siie is aitered ar the irrterided use ctlanges, the petmii shail became i�valid. . _ • Cwner ar f,l /-d y Date PC}iD, rev. �61271U2 ��: sf I�I�I�.� ��T - -� �c � �� I��ca�aa-o av.aaa �na�.m.Il IE-7I � �..Il�l�a SI'TE PLAN Name ✓' �� . Tas Map # �/ �D p i3 # / / � Subdivision ' Section t r —/�O Authorized State Agent Date System componenta reptesent apptoximate contours only. The contractor musi flag the aystem prior to begintvng the ins[allation to insute that pmpetgtade is maintained S•'�rc ✓��-��kJ`O�"as�.� T�a�S n�_ �T- o� .. � . PCHD, cev. 09/]2/Ol ��.�� .�� `--�= -� � � ��-�-�- �aa�n��n�n�n.�m��.� ��a�.�.��1in. WELL PERMIT � PI.EASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Map #: d(i Parcel # I/� _ Township � Applicant: Subdivision: ��Dr? ��a;. j�,$� t-> �" Section: Lot: � Location• � � � � �� r � � � Ty�e of Water Suvvlv: Requuements• ✓ Individual Community Public Site Approved y ,�� Grouting A roved by 1 '�c7 Z Well Log Well Tag Air Vent Hose Bib Concrete Slab Well Driller. �r� �� Well Approved By: Date: '�See Attached Site Sketch�* Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from anp building foundation. Odzer conditions: .S�- S.�e PC�ID, zev. 09/07/01 `_��.�� D�� D � 3 d��f `_" � � ��T�� ° ° � ��-,►z� �!�l��. ��,.,,-,, ��.� ��.��. D�o ��1 I r- 7- v a- / C��'ov�.�'Log Owner: ,/�� r� � �� jG,,,i( __ TaY Map?� Parcel # /� Location: Subdivision: Lot # /'�_ Well Construction Distance From nearest Property Line (Minimum 10 feet) Distance from Septic System (Minimum 60 feet) Total Depth: f�f� ft Yield: � GPM Static Water Level: —�� ft Water Bearing Zones: Depth �-, ft��;�� ft��7„� ft� ft Casing: Depth: From _,� to �37 ft. Diameter: (� � in Type: Galvanized Steel IJ� �i _��__...�_— � Weight: Ttuckness: s/,�r,� Height above Grounci: �_ in Drive Shoe: Yes No Any problems encountered while setting casing? Yes r/No If `�es" give reason: Grout: Neat: Sand/Cement Annular Space Width Method of Grout: Pumped _ � Concrete GraveUCement inches Water in Annular Space Yes No Pressure Poured ,t/ Depth to Materials Used: No. Bags Portland cement �. �- Weight of 1 Bag _�iZ Pounds If mixture (san avel, cu ' gs) — Rario to ID plates: es _ No 4 x 4 slab es _ No Drilling Log � Location Drawing From 'I'o Formation O v� �c bV sGG,�I� ,/ v � �o s�. �� c�5 � ��} h�ct �u��f (� � : f yr,l,�1(y �G • � �j! � �Zox�� o F� I hereby certify that the above information is correct and that this well was constructed in accordance with regulations set forth by the Person County Health Departm nt Signature of Contractor ,��` ID# �0,�-�{ Date /(—% ��