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mprovements Permit (Established/Recorded Lot) _ Reinspection of Existing System ( oan Closing)
Improvements Permit (Unrecorded Lot) _ Repa' eplace existing Septic System
Improvements Permit (Mobile Home Replace) _ ermit for New Well
Improvements Permit (Addition) _ Replace Existing Well
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Bacteria Chemical Petroleum _ Pesticide ,_ Lead
1. Permit requested by: (� l
o nw er rospective owner/agent: ic�c Uo I�-
Address: � ! y Y� � a-�i'e � �
��� �I,� �. „►, ri� - c, 2'1 '� 0 3
ome Phone #: �1'l S-S 5`� "� ZZS
usiness Phone #:�L�j gYv - �o �
, Name and address of current owner: �'� �' �-
f� j�i Y� ,'� �<< S 4"
�,,, , n�w-,- n► � c 7�� v3
. Property Description: Lot size: 1�.1 �O
. Tax Map
� Parcel#:
Townshi
. Directions to property: State Road #& Road
iames, etc. _ ,� � ,
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„✓ r 3 r
0
Number of oc
�./ l2t�-�i
or people to be served:
7. Dimensions or Proposed Structure:
Width: ��`� �
TlPnth• h�r
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?
9. Water s ly type:
private public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No ❑
If so, identify location:
10. Type of structure/facility: Proposed: DExisting: ❑
Type of dwelling: ,_,�,�'
House: ❑ Mobile Home: l� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �
Garbage Disposal? Yes ❑
Basement? Yes ❑ No f so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
'PROPOSEDSTRUCTURES.
;reby make application to the PersOn COunty Health Department for a site evaluation for the on-site
vage disposal system for the above described proper[y. I agree that the contents of this application are true
i represent the maximum facilities to be placed on the property. I understand if the site is altered or the
�nded use changes, the permit shall become invalid. I understand that before an Improvements Permit can be
ued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
.ivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
: site by the Health Dept., this application shall become void and all fees paid forfeited.
. .. ...., �'- -' • ----
permit Issued L�
Permit Denied ❑
Plat Observed ❑
Signature � � � Date
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9. SiiE CLASSIFlCATION(SEE BELO� O C�
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SOIL SERIES
SSUITABLE PSPROVLSIONAI1.YSlJiTABLE U•UNSUfCABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
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- � 81061
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIl'ROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity sha11 be issued until Authorization for waste water system construction
has been issued.
Tax Map # � y%�
Owner/Contractor
Locatipn/Address
3f�- lot c� n
Subdivision Name
le
Parcel # l �5
Township F/a�-r ` ve� �
ar Date o'J'� �
l�w � T� L- i n fo �� �or1 i a�Q �'�a-�F
S.R.# tl�� /� 7
¢�Ps• Lot# a, b
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area ,(c Size of Tank GGop
SFD Mobile Home ✓ Size of Pump Tank /�
Business # of Bedrooms_?� Nitrification Line �CY�' 1c 3
Max Depth Trenches �?fo i � .
Permits may be voided ii
Well and Septic Layout by
Comments:
Date �/-io. q � Installed by,
ell Permit Paid 0� WELL SYSTEM SPECIFICATIONS
Individual ,/ Semi-Public
Public Replacement
Site Approved t�
Well Head Approved
Grouting Approved
Comments:
by
Required Slab � __
Air Vent
Required Well Log
Well Tag
Date — Installed by f{: �g,P�C�� Approved by �o
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 information
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
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Date: '
Owner:
Location/Directions:
PERSON COUNTY ENVIRONMENTAL HEALTH
�' WELL--LOG =-.:_. � ,-_.. '-,„-
Stibdivision N�une: �. • �
Drilling Contractor: �
3
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sR# � �-� '
Lot #
WEI.L, CONSTRUCT'ION
Distance from Nearest Properry Line �f(��' Distance from Source of
Pollution /C�Q �
Total Dep.th: l�"� Ft. Yield: t� GPM Static Water Level .3a Ft.
Water Bearing Zones: Depth �Ft. ! C.�? F� F� Ft.
Casing: Depth: From �? to �b' Ft. Diameter: �� Inches
TYPE: Steel � Galvanized Steel ✓
If Steel, does owner approve: Y�s No
Weight: Thickness: ,/�',� Height Above Ground: / y Inches
Drive Shoe: Yes_� No . =
' Were Problems Encountered in Setting the Casing? Yes No �
If "yes" gi:'e reason:
Grout: Type: Neat Sand%Cement .•-�' Concrete
Annular Space Width Inches
Water in A.nnular Space: Yes No
. _ . Method: Pumped . -_ Pressure � Poured � . � .:;
Depth: Fr�m d �o �c� Ft. �:�'
Materials Used: No. Bags Portland Cement Weight of .1 bag lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes � No � �
� 4 x 4 slab Yes � No
�
0
I HEREBY CERTIFY THAT THE ABOVE INFORIviA'TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH By�THE PERSON COUi�'I'1' HEALTH DEPARTMENT.
Signature of Contractor Date