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A40 151-� i•r:i;:.ui� �;uiii� r� I•:IJV I.l(IJIJI`II.IJ I AI. III:AI. rii WELL LOG Date:��-- � Owner: ���1� ,M ► L�� � SR# Location/Directions: , , , ., �'„1���:�ric��nn T�Tmm�• � ' i.v� �t Drilling Contractor: 1li 1 N , -- WELL CONSTRUC'I'ION Distance from Nearest Property Line Distance froin Source of Pollution Total Dep.th: Ft. Yield: � GPM Static Water Level Ft. Watcr Bcaring Zones: Dcpth 2�5 Ft. F� Ft._ Ft. Casing: Dcpth: From O to�_Ft. Diamcter: / Inches TYPE: Steel Galvanized Steel ✓ If Stcel, does owner approve: Yes No � Weight: Thickness: . Height Above Ground: Inches Drive Shoe: Yes No . Were Problems Encountercd in Setting the Casing? Yes No If "ycs" bivc : c�son: Grout: Type: Neat Sand/Cement ✓ Concrete Annular Space Width Inches Water in Annular Space: Yes No Method: Pumped Pressure Rou.red ✓ � De�th: From � to 2 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 I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THTS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY�THE PERSON COUNTY HEALTH DEPARTMENT. . , , �_5�6 � Signature of Contra _ D1tc � � � H O � �,d 0 1�7�� ni;q0, P.e�� 3�� 0 �� Improvements Permit (Established/Recorded Lot) I Reinspection of Existing System (Loan Closing) Improvements Pernut (Unrecorded Lot) Improvements Permit (Mobile Home Replace) Improvements Permit (Addition) _ _ Bacteria l. Permit requested by: _ Repair/Replace existing Septic System Permit for New Well _. Replace Existing Well _ Chemical _ Petroleum I _ Pesticide � _ Lead me Phone #: �99 33g3 siness Phone #:�% �/7z 7. Dimensions or Proposed Structure: Width: �' T�Pnth� zc4 � 'e- 8. What type (if any, additions, expansions, or 'S73 replacement is anticipated to the structure or facility that this sewage disposal system is intended to serve? Name and address of current owner: on: Lot size: / ZZ.4c Tax Map#: Parcel#: _ Townshin:. Directions to property: State Road #& Road , ames, etc. �� ��� "��'�'`'' // ! S� ���s d�- ✓�.�ii.S /�' l� l n�, � � Number of occupants or people to be served: _ 9. Water su ply type: � private public ❑ community ❑ spYing ❑ Are any wells on adjoining property?Yes C� No ❑ If so, identify location: ,�oT � � /l�i�vr� 10. Type of structure/facility: Proposed: C�'Existing: ❑ Type of dwelling: House: C�'fvlobile Home: ❑ Business: ❑ Type of business: �i4 Number of Employees: �✓� Number of bedrooms: � Garbage Disposal? Yes ❑ No Li Basement? Yes ❑ No G�f so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the PeI'SOn COunty Health Depal'tment 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. z Signed Owner or Atfthorized Agent � Permit Issued �' Signature � Date 3'l3 —,i 6 . Permit Denied ❑ Plat Observed ❑ ; `, '. FAC7'ORS-STiEEYALVAi70N :;; . . ;i: . .... ; ARFA1 ; .. ARFA2 . ; ' AREA3; ARFAd _ _ . . _ . _ 1. SLOPE (%) S 5 S S � Z- 3�� U � � 2. SOII. TEX.TURE (12•36INJ �i��J S S S (SANDY, LOAMY, CLAYEY, NOTE 2:1 CLA� 5 PS PS PS U G'I..� U U U 3. SOII. STRUCi[IRE (12-361N.) S S S (CLAYEY SOILS) S s� �! PS PS PS \ U U U' 4. SOIL DEPIH (INJ �/4 . S S S P Ft�L,V PS ' PS PS �� f � U U U S. RESTRICIIVEHORIZONS((N.) S `� S S S (IMPERVIOUSSTRATA,ROCK) /fIYJ/v �-` U U U U 6. SOII. DRAINAG&GROUNDWATER � J� S S S (EXTERNAL R INTERNAL) �`� PS PS PS U /�C � ' U U 7. SOII. PERMEABRITY S S S S (PERCOLOATION RA7"E) PS PS PS PS U y,� �T�� U U U 8. AVAILABLE SPACE S S 5 S ` PS PS PS U �✓ U U U 9. SITE C[.ASSiFICATION(SEE BELOW) a � . SOIL SERIES SSUITABLE PS-PROVISIONALLYSUTTA6LE U•UNSUITABLE RECOMMENDATIONS/COMMENTS: ��''' 2 y" r"� N v�' T.c� Nc �,/ /� �/`��'� �-� �v ,�,�/+�c: .S �,�cl � iv' Ti`l G' � � SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope patterns, etc.� C:WMIPRO�DOCSIAPPSEC.SMFINANCE.PC � � a w � a B 0�39 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT 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 # fi '�o Parcel # If/ Zoning Township ,t�v5 N y /='°�� Owner/Contractor y✓/t ��� M ,�. �r�a Y�v �,k Date ,3 -�.�- 9� Location/Address y 9S T/� a� �o a f/ /� .� v�s ��,a a LoT J.5 11/v L�F� A���'v�i�' _/ icil rL� S.R.# /� y/ Subdivision Name ����rTitY �.Poo�c€ EsTA T"-�..s Lot# ,3 SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area /_ zZ A Size of Tank �000 tr� L. SFD 1/ Mobile Home Size of Pump Tank ,�//,� Business # of Bedrooms � Nitrification Line �ac ` x 3� Max Depth Trenches z z'' -� l,I '' Permits may be voided if s�te is te Well and Septic Layout by Comments: �Z " - z �_" M,� !•�._�.1 or intended use cha � Date !0 1�� Installed by �f.' lP�� S Approved by �, C�. C_a-2��, r�lr, �� Well Permit Paid WELL SYSTEM SPECIFICATIONS Individual Semi-Public Required Slab � Public Replacement Air Vent c� Site Approved Required Well Log Well Head Approved ��- Well Tag r �G� �outing Approved_ Comments: Date Installed by�R�/k�� r�oicc.�an.�sa4pproved by � �� This report is based in part on information provided the homeowner or his/ber 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. 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