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Improvements Permit.(EstablishedlRecorded Lot)
Im�ovements Permit (Unrecorded Lot)�-
ts Permit (Mobile Home Replace)
Improvements Permit (Addition)
t , , 02- 1 I-9'1
_ Reinspection of Exiscing System (L.oan Closing)
Repair/Replace existing Septic System
Permit for New Well
_ Replace Existing Well
�Permit requested by: .
wner/prospective owner/agent• ��✓//�a�- � B�a����/
�ddress: . ,220 �' mo`''' �?�f _
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ome Phone #: 5�9�33.Zi
usiness Phone #: .�y� �:��'� �"t ,Z33
7. Dimensions;or Proposed Structure:
W idth: �� C x� �
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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?
Name and address of curren[ owner: 9. Water supply t}�pe:
S 0.M� ` private� . public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes`� No �.
If so, identify location: �� CQ,�ntrv " ru�f� //�
Prooertv Description: Lot size: -� . g 7
� C_ �a:�born �VC 2''!.�'�3
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Tax Map#: A�� L� � 2
Parcel#: ��+Q �`�'�'���
Township: B�� �rkT�'.". - ����
Directions to property: State Road #& Road
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�pe of structure/facility: Proposed: �xisting.
Type of dwelling:
House:� Mobile Home: 0 Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: 3
Garbage Disposal? Yes ❑ No�
Basemenc? Yes ❑ No� If so, # of basement fixtures:
6 Numbec of occupants or people to be served• �. � `
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES. �
I hereby make application to the Pet'SOn COutlty Health Depai'tme onients of th s auplic�ation ahe true ite
sewage disposal system for the above described property. I agree that th P
and represent the maximum facilities to be placed on [he 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.
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Owner or Authorized Agent
permit Issued L�'
Permit Denied ❑
Plat Observed ❑
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RECOMMENDATIONS/COMMENTS:
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SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.� C:V�MfPRO�DOCS�APPSEC.SAIFlNANCE.PC
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B 1506
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT 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 # A yo Parcel # i 6o
Zoning Township g�.� ►.� -� � � �Z ��
Owner/Contractor �J � L L 1 A T�1 H. C; L A GK wl �� Date Z- � 3-��
Location/Address
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i C FT S.R.#
Subdivision Name � o �., N r,zy a rz ���k �= Lot# � 2
SEWAGE SYSTEIVI SPECIFICATIONS
Repair Lot Area 2. f3'7 A � Size of Tank /LbD l,a �
SFD �/ Mobile Home Size of Pump Tank ,i//�
Business # of Bedrooms � Ntrification Line �oo ' x3 '
Max Depth Trenches 2�/ "
Permits may be voided if site is
Well and Septic Layout by_�
Comments: Zy " M,a.X
DateL l �9 Installed
ell Permit Paid
iividual c/
blic
e Approved ✓
ell Head Approved
or intended use ch
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�n-vL� ���-� Approved by Gv
h�2,--� 9-1 `7-`T7 W�
� WE�.L SYSTEM SPECIFICATIONS
Semi-Public Required Slab �_� - �9 � ___
Replacement Air Vent 1/��
Required Well Log
l✓ !/ I I-�o �' 7 Well Tag 1/
i'I �/
Comments:
�
Date /- �' Installed by � ','a �.� Approved by
This report is based in papt 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 fro�n 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 fui�ure or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
�;� �cc� �T�2J�o �s �C
P�RSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date:�-t �
Owner:
Location/Directions:
SR#
Subdi�����on Name: ��- Lot �# LZ
Drilling Contractor: �t��3K�� u��t�,1 �M So.� iN �
WELL CONSTRUC'I'ION
Distance from Nearest Property Line Distance from Source of
Pollution
Total.Dep.th: Ft. Yield: �'� GPM Static Water Level Ft.
Water Bearing Zones: Depth Ft. Ft. Ft. �t.
Casing: Depth: From to Ft. Diameter: ��4 Inches
TYPE: Steel � � Galvanized Steel ✓
If Steel, does owner approve: Yes No
Weight: Thickness: • � Height Above Ground: Inches
Drive Shoe: Yes No . � i
Were Problems Encountered in Setting the Casing? Yes No
;f "ycs" givc rcason:
Grout: Type: Neat Sand/Cernent Concrete �
Arulular. Space Width 12 Inches
Water in Annular Space: Yes No
Method: Pumped Pressur� Poured ��
Depth: From O to 2� Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag__lbs,
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Ycs � No � '
4 x 4 slab Yes ✓ No
I HEREBY CERTIFY THAT THE ABOVE INFORM�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON COUNTY HEALTH DEPARTMENT.
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Signat�ire of Contract � Datc
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