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A40 123Yerson County Health Department Existing Sewage System Report Fo r: � Mobile Home Replacement . Addition Requestee: �� I� f cC -�• ��d S�C� Home Phone# �7-���� S�f Co%N a l _,�',s�`• /�c� Business# �s��v�o� uC 2757� �pax Map# ��� I2.3 Location/Directions : L.o�o �, iQ � �S �Q�tcS Z2 (� Original Permit Located '� ��G'��Ou � '�%���� '�br 3 ���'°i'�s Septic System Uesigned For: ttesidential '� Business � Other {specify) # Bedrooms _�. # EmPloyees Other �, �-zO-99 Uate Tnstalled /o -%- �� Water supply � Type ot System �oUu<N ��o�� Nitritication Line y� �X3' Tank Size �UdU _ Certif ied Operator Required �° On site wasL-ewater disposal system showes no visually apparent malfunction on y- 20 � 94 Yermission is granted to: ��iQ�9� � ���`'�Or �"''-�J 1"J'� — �� .3 �drvo.. �v��� l•%�� According to the attached site plan.- I)�/ / %� /� Comments: /SP.ep %7o�.s� S "'�" T�or� ,��cP1'ic a�.eQ � Environmental Health Stt�u. �� 6'"` ' � �. , ,. , � . . �:. :. � ' ,. , .. :�,� _ ------ -- y �-s�9 DATE . . :� �. a � w� . r "Y'Y.i:r�:i t<�t '�.P •�'•'y1 �. v.;tRa,�i,y�p �'r:+y rt� t � �; F�.ey<< p�tGr�d��!�6: , - � .�, .�.� x� qt, � N � ,,:. � : � � .r�.7 �, ��: , x�, ► �.� .. 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'/J� ��« i � (� � � ' .i { °��� . . � �A��`/ � � � t�. O 3?B ! �b � � '/ � i n ' Y � �: � , +� � iti' . � . . �K�' ' V t . � . Q`�ti � . �1i'R�' y� i�.� '..� � .- � � ' .'(/), <� - {�y ��� tiO � '4,, � ' s' < < � . '' .0 '�`;iR;� S+ 11�9 v � � \QOO � �O � t.. k} 3 ;, ~ i 4 t ) �.! � 2 � �� �; `�r,,% . r � ..;�e . � !+� 6`y' .i�> . � . '� [_ . . . {,: � � � '•; � i � �.. t i�� � J � � �,j�� � , ,b v � � e `, �, ! � � � , O'" `�'^yi. \ io q�. . , . . . + "' A . ` r ` ' � `r � `� i-, � ' "�' e . � ti � + +"�`,; yoi /i / . � Q [ n . . : � . r ; x t '� . '. M � � ,� .. , , � � r�. r � �. �, pF . ^ > > r� �r: >� �.. ��i� .�` � � . . . • , s .! �.l .��J �-'V . O � . � .(� t � �� � �� ��� r � i� � V � � . / ' , ' '' ` � + A ! � ` � �'.. �� ' . / �� /_ . .. � . �� > f .�! � � � {� � i� C r l ,.. . � `��.� * ..J F -.�jL�. . . . . � S . , . . . . . . a� Amount paid �66� /� Receipt l� ' �'j� � � ��`�"1 • Date � E-+ O a Permit requested by: . nerlprospective owner/agen dress: ��'� �r�'r�t�i�.'i. �z >. � ��- � w � Home Phone ., a usiness Phone z C . 7. Dimensions or Pro osed Structure: � ��oc��'�flY Width: � � X � 6 _ ' � Depth: �` �`� �`'�'� 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? 2. Name and addreSs of,curren[ owner: . Property Description: Lot size: . Tax Map#: Parcel#: _ Township: � ��- � � Co I oura � es� . Directions to property: State Road #& Road � ��' �u�d 1 e /� � 1' $'y ,� /°v w,� � 13� � � a� . Number of occupants oc people to be served: 9. Water su y type: private public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No [�. If so, identify location: �pe of structurelfacility: Proposed: �Existing: Q Type of dwelling: , House: ❑ Mobile Home: (Q.Business: ❑ Type of business: � Number of Employees: Number of bedrooms: 3 Garbage Disposal? Yes ❑ No -L�1 Basement? Yes ❑ No�I If so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AI�ID THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the PeI'SOn COunty ���alth Department for a site evaluation for the on-si[e sewage disposal system for the above deseribed property. I agree that tlie contents of this application are tcue and represent the maximum facilities [o 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' ttie evaluation of the site by the Health Dept., this application shall become void and all fees paid forfeited. �°'�1' e /f � � , �-`�, � ;� ' r � \4 P f 1�... / '��4 . , � r i � / ��,r2.�„ - �:�--� � �-:��_r` `,+: i fi Signe� Owner or Authorized Agent ' U��r�c ��o� 2 �r' r � 3 ����°•, � ��pa�� P��►,'� �� � 2836 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE �ITE, LOCATION IMPROVEMENT PERNIIT Not 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 # � �0 Parcel # �� Zoning Township, �%a ,'ve� Owner/Contractor /i,' �e � ,8��.s�c� Date 3— �-5�I Locat'on/Address /s7-S i,. .�'� ;��� C��% �..Q / Fs�a�s o� �� ��. v.� . a� �" ,`'7'av.sc o•• Subdivision Name � SFD S.R.# Lot# c� a � SEWAGE SYSTEM SPECIFICATIONS • Lot Area % Uy c Size of Tank /�d �x%J Mobile Home ✓� Size of Pump Tank :ss # of Bedrooms .3 Nitrification Line a$o W� /��pla�;.�y � f3u��oa,• N,� V Perm�ts may be voided if site is al red � Well and Septic Layout by o•.. a Comments: � v -►t c� -'�1 /� i . .L-i'nn _�.[D it_ ' d..� . Max Depth Trenches i � � �,�roo�• �v�d4 X3' �'x;s��� y,� !.�>�.. � I�D'x3' 3 8��� or intended use changed. � �, � � � 1,c'�^a G A v/�p r2�u . � �` -- ^--- ' � Date �nstalled by Approved by Well Permit Paid ❑ WELL SYSTEM SPECIFICATIONS Individual Semi-Public Required Slab Public Replacement Air Vent Site Approved Required Well Lag Well Head Approved Well Tag Grouting Approved Comments: Date Installed by. 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 informatio� 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:\amipro\permit.sam O1/95 rev.l.l � (� �4 ""v The Distric� Heal�h Department ,�.:� �.#� C,4SWELL - CHATHAM - LEE - PERSON COUNTIES � „ � s; Wa�er S��pply and Sewage Disposal �' �, 4k - _..•---. � PROVEMENTS PERMIT No:�_ �� � � � � A � Tnln h � r �`. ` r r + �� . � ��� O�ner:3 '" L`ocation: �l-.�� p � , �' _.1�� ��• � � q, Contractor: _ � � p�,�r�,�'� Wsler Supplp: 1� r ki;�: ? i. sf41."? � ,�.� . � ��}� ►� :i %�� � -- Public _ � {, 1 Seaage DLposal .�acilities: No. drooms � Dishwasher, Disposal, washtng niachin other au�oma 'sc.,a,p„�liances ,.._.. Stze oi tank: Nitriftcation line: i� 1 T � ! , t a 1 , -:. � � � ��Other tlispQsa facility: � � ) � t ` • (%I/ �y�) v L �"� Water supply and ��sewage dispos�� facilities location, installation and protection must meet state and local regulations. Septic �tank should be pumped out every 3 to 5 years and shall be main- tained by owner in such a manner as not to create a public health hazard. Septic tank and nitrification line MUST BE INSPECTED AND AP- PROVED BY A MEMBER OF THE DISTRICT fiEA�TH DEPARTMENT STAFF BEFORE ANY PORTION OF THE INS'�'ALLAT O�T IS COV- ERED AND PUT INTO USE. '�`� t � ��� ,, -�, � ._*. _��. � 3 !� � � � � • Date approved: � Well:lb2 � �fi��Ct,�� BY:. S1gT1Q • ' i__,�' Sanitarian ' � Counter-f • ' �, �igned � � - (O�Tner or hi's repiescntativ�) . .; ` � ��Cerf'if'icate of Completion ; � � - ; � �� �, ^,-, Date Approved: ` '' By: � �- /[!� . Sa arian ; (OVER) � Location of well and sewage disposal facilities sketched on back. 1 • •+ �� c�3 f': ��z�:� x: 1 ��� �: � � � U� '. �' � . �'�'! `� .. , � (1.�.: ' 'Z � . �, � � �D �i:.�:, :o'� �. i ro �:.� ..,r� ': `.�.. '�O�""�. 3 ;.:�;�: *�•.- � � � �. o 5.��.-..:.~....� M � . o . .�.�:� �� '•o :o.. .�. :' �..s�w li � m m w ^' j t�D � p . y.. .�,=y.. ... ! , `�. �n:�'J'• i :` . ?«�-,•..0 .�• � . . ��:'�o. '�::°° . a, • �C? .�"o:� � e .. •.., �; � � .' y ' ti+� ,�i pr. . . . : w � lV � �..F��.�� � �,. � � � .�a�' �. - ���,,,(� � 'O�+ .� t N � y � �.hF �: � �f ',���� R . � :� � �; ,�,'i' �, � . :1 ;� � � ,� o �� M ro . � � i '+ o : •`. . f •," ;•:� y � :_� � �. � ; .�� y �� 1 . � �� � r► •.;�, '� ' 5 �,� n . L � km .� �.^.. �. 4 •� � � ����, � ,u .�.! t ?J,� �7� I S@ � T" '.d .�. � ' ,� ?: , � ,� � k ;p. :; \.�f % ;'.W �--�