A40 168��O�'''-II
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( Improvement Permit
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APPLiCATION FOR: Date Received: � � �r ��
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( ) Subdivision ' ( ) Other 3
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1. Permit requested by:�� ' ��� Home Phone� ',r �%
Address: — O -------Business Phone_ y�� i �I
2. Name and address of current owner: ����-.� 1,���l���.� ���,y �Ok�o�t�
3. Property Description: Lot size �,�� ��2� � Dimensions:
Front �} 1(-��� Left 310�� Right ��O �" Rear 3�`���
4. Tax map No. Township: r o� Block No. Lot t1o.�
5. Direc�.ions to property• State Road No. 6 Road Names etc.
� tiG I � _0 � . \` .�_� � _ ��_\_ \,-._ , a__� �- 11�1\ _ (�„
6. Permit requested for: New Installation �/ Repaired
Additional Renovation re-using present system
7. Number of occupants of people served�
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8. Dimensions of Proposed Structure: Width i� Depth 3s
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9. What tyge.(if any� additions, expansions, or�replacement is a.�i.icipated x
to the structure or facility that this sewage disposal sys�.em ?s intended a
_ to se�'�e? . ,a
" � �
.10. Type of water supply: Well�yes no: If no, name source of water
supply: Are there any wells on adjoining r
�.property? _ If so,.identify location. �,
12.
— - - --- -- -
Type of structure or facili y: Proposed ✓ Existing
Type of dwelling: House� Mobile Home Business •
Type of business � Number of Employees
Number of Bedr6oms� Number of automatic appliances�
Basement�_ Number of basement fixtures
Clearly stake sll�c�rners of the property and the corners�of all
structures. '
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I hereby make application to the Person County Health Department for
a site evaluation or existing system evaluation for the on-site sewage
disposal system for the above described property. I agree that the conten
of this application are true and represent the maximum facilities to be
placed on the property. I understand that if any changes are made without
approval from the Person County Health Department, the permit will be void
Any permit for a system is non-transferable without prior approval of the
Person County H�alth Department. Permits are valid for �70 months from dat
of issue. . ,( „ �
SIGNED
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. . . i�r,r::.r'ys�..�..-.t�:•i`ir.::J
t.ac 1 stl.2so •�>'��
l.oc 2 9,450 • PJuoo
Loc 3 8,500 (,Q(,�'f
l.ot 4 P,960 ��v�
Lot 5 13,780 ��SpJ �,•
l.o t 6 R, 000�—��
l.ot 7 8,O00 6/
i.ot 8 7.'I00 �'q33,
Lo c 9 7.800 ��✓ 1 V
Lut l0 7.sU0 66��
t.oc 12 iz,boo �34�
l.ot 13 14,885 �q6
Lot 14 14.985 tf�Q�.
Lot 15 15,�00 �+�.��Q6
I.ot IS 28,000 Z,QZ2.
l.ot 19 12,400 µ'�4�
Lot 20 16, 140 /pO�a
Lot 11 sold ' �' W �a^�ook
Lo [ 16 �..perr�-
Lot 17 sold
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PAIIIID Horv�y. N�ama
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N. 69. �� :W ••� • — I.. �
� q� ¢.. 10 SR. 119? � !
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' A �nt paid I�`��
Receipt dl ` �06U
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Improvements Permi�(Established/Reco"rded Lot)
ImpFovements Permit (Unrecorded Lot)
. �-�2-q'1
Date
_., Reinspection of Existing System (L.oan Closing)
ir/Replace existing Septic System
Improvements Permit (Mobile Home Replace� ____ Permit for Ne.w,Well
�_ Improvements Permit (Addition) _ Replace Existing Well
I . Permit requested by: .
owner/prospective owner/agent: "
Address: •�) 4 h N 1g ��� �-� o � S �
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ome Phone #:_
usiness Phone #:
7. Dimensions or Proposed Srructure:
Width: �4 o X50 � S�� �a-.
Depth: Z°o Q ,
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 current owner: 9. Water su ply t}pe:
-�e�Y �J ' �' \�� � private public❑ community❑ spring❑
� Are any wells on adjoining property?Yes ❑ No [�
If so, identify location:
Description: L,ot size: I� �`7
'I`a Map#:
arcel#:
Township: �u
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. Directions to property: Sta[e Road #& Road
f ames,�tc.
: A e.�� s S
�s�u-� S
�-�c- o �.�. Co �,�, �,1 �-r y '(3
_ t141-
I0. Type of structurelfacility: Proposed: �Existing: Q
Type vf dwelli :
House: Mobile Home: C� Business: ❑
Type of business:
Number of Employees: .
Number of bedrooms: 3 �
Garbage Disposal? Yes O No �
Basement? Yes ❑ Na�'I� so, # of basement fixtures:
6 I�tumber of occupants or people to be secved: � '
CLEARLY STAKE ALL CORNERS OF THE PROPERTX AND THE CORI�IERS OF ALL
PROPOSED STRUCTU�tES•
I hereby make application to the PerS0I1 C011IIty �Calth Depaxtmeilt for a site evaluation foc 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 Pecmit 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 propercy to-the Health Dept. wi�hin 60 DAYS af[ec the date of the evaluation of
the site by the Health Dept., this application shall become voic� and all fees paid forfeited.
.. � �
Permit Issued L�'
Permit Denied ❑
Plat Observed❑
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Signature �-�1 � ate
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'"k'�t�"'`Si¢.e.`r'3}�a�x�,�iyasD.F�cro.. . � ... � . { r��.i�`.,��t ��`�k;���"�'�`' a �..�. .:.a�'ys.k�'ti .� :�.,�`a- a�' 3���� +'G" � �. fy"v` . �:« �< -_ 3�tx1 x�£ - �'x .�:�a�...
RS�SiIEk�!ALUATIAT� L €� �" ,11RF�'T ;-r, A.-�.:�,. �� �: �'�`�s'Fsa.._:...a.: '+��re�
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1. SIAPE (A) ,�� S S S
PS ay —/ PS PS PS
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2 SOII.TIXTURE(Ib36lN.) • �p� S S S
(SANDY. LOAMY. MYEY. NOTE 2: t Ml� PS PS PS PS
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3. SOiLS1RUC'fURE(12-36IN.) S S S S '
(QAYEY SORSi PS 3� PS PS PS •
U U U
3. SOILDF37'H (IN.) 5 S S
i PS K PS
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3. RESfR1CTfVEHORRANS(Tit.) S � S S - S�
(IMPDtVIOLS STRATA. ROCK) � PS K PS
v v u u
6. SOILDRATNAGFJGROUNDWATER S � c7 S S S
�EXTERNAL� WhRNAL� U Mo}rf'�� U U U
7. SOII.PE7UdEABIl7TY S S S S
(PIItCO(AAT10N RA7 El PS ` 2 C��i PS PS PS
• '. V ✓ I f-� r- U V U
�. AVAitJ1HlE5PACE S S S S.
PS ps tS PS
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9. SfIEC1.ASSIF7GT10N(SEEBELO�
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SOtLSERtES ' � •
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S•SUITADLE pS.tROYlS10NA1�.YSUTiAIII,E lt•W7SUffAIILE
RECOMMENDATIONS/COMMENTS: _- _ _ __
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.) C:MMfPRO'1DOCS�APPSEC.SF1 FINANCE-PC
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ITFIEI
p. 75
p, 35
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JERRY E. WHITFIELD
p,g. 152, P. 75
p,g. 188. P. 353
CONTROL � �
CORNER �
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ICHOLS
. 558
Amount paid �vQ�UO
�,Receipt � � �� 3
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Improvements PeRnit.(EstabtishedlRecorded Lot)
Imt�ovements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
��mprovements Permi[ (Addition)
i-�-��
Date
Reinspection of Existing System (Loan Closing)
Repair/Replace existing Septic System
Petmit for New Well
_ Replace Existing Wetl
1. Pecmit requested by: .
�wner/prospective owne agen
Address: - L 2 `
/ /� �.lo lo /%U/�/�
7. Dimensions or Pro�osed Structure:
Width: /��/X/� S7%Y/z�o•c/
�/Dir//L�S Depth: � x t Y ���z�z�'�/�i �
�� 7 8. What type (if any, additions, expansions, or
�7'��J replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
E-iome Phone #:
Business Phone tt: 3,�! _�:l�y �5"��
2. Name and address of.current owner: 9. Water supply tSpe:
/ � C�'— 9� �iP�'' f����� private t� . public ❑ community ❑ spring ❑
/1/U9� /%.¢U�S �E'U�y/ Are any wells on adjoining property?Yes ❑ No p.
�20 �'�v�C'D ,/flL' If so, identify Iocation:
. Tax Map#:
Parceln: _
ion: Lot size• LJ �
26
� Y _ /-'�,�i� TLf.f •
Directions to property: State Road #& Road
ames,gtc.
: rl/. C'. ��l To il/�/�-� ��L/S /�O
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��d 10. Type of structurelfacility: Proposed: DExisting: Q
Type of dwelling:
House: ❑ Mobile Home: C7 Business: ❑
Type of business:
Number of Employees:
,9� Number of bedrooms: _ _ __- �
Garbage Disposal? Yes ❑ No 0
Basement? Yes ❑ NoII If so, # of basement fixtur�s:
�6. Number of occupants or people to be served: ( I
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PeI'SOIl COunty T.3ealth Department for a site evaluation for the on-site
sewage disposal syscem 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
in[ended use changes, the permit shall become invalid. I understand [ha[ 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 piat of the property to the Health Dept. within 60 DAYS after the date oE the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
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Signc� Owner or Authorized
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B 1779
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION Il�II'ROVEMENT 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 # Parcel #
Zoning ��C S�}-�� r���nship � T Bvs N Y Fo� Y
Owner/Contractor �1;�i1N �3 . 1�l � c,�l v � S Date -7,c3 /S �
Location/Address y�s �/� �/v.4 � DA vi.� T2� vn/
R/G� T 6'C-'rD.�2C �1aC Brp� /�i%7� _ S.R.# [/Ti�
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area j,/'% A� Size of Tank /Ooo l�,a�
SFD ✓� Mobile Home Size of Pump Tank
Business # of Bedrooms _� Nitrification Line oo ` x 3'
Max Depth Trenches �Z ,� "
Permits may be voided if site is
Well and Septic Layout by�
Comments: �S�" �IA
Date Installed by_
�tt� � '7Z
Well Permit Paid,� WELL
Individual Semi-Public.
Public R,eplacement
Site Approved ��
Well Head Approved
Grouting Approved
Comments:
Date Installed by
or intended use ch;
f�q
Approved by,
TIONS
Required Slab _
Air Vent
Required Well Log
Well Tag
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 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 proyided 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
� � .
Yerson County Health Department
�xisting Sewage System Report For:
Requestee:
\
Mobile Home Replacement
✓Addition —��n('�rn �`g�����/
f �(�a.c�l�`�-�. � Q.�Ten S
� �o r��n.� nQ �i ,s �
����CO I �� 2 �s`�� _
Location/Uirections: �1 �L J ��l_, �
t-t � � � �P . �, . � � Yl�v� . Q Q C71� ll � ) -'
Home phone#
c�td n�o�t.5�_`3 (�►� -159 c7
Business
'Pax Map# � ��—) (o�
I� „ _ � , t'��
Original Yermit Located
Septic System Uesigned r'ar:
Etesidential _�� E3usiness Other (speciEy)
# Bedrooms � # Employees Other _
llate lttstalled Water supply � �.
`Pype or System L-(�J%1 ���'YJ� �� ls�C
Nitrification Line
Tank 5ize
U I� `�
Certified Operator Required ( �I U --
On site wast-ewater disposal system showes no visually apparent
malEunction on I lSlg �
Yermission is granted to: � I� n1�t-� ��� �F�m� s
According to the attached site plan.
Comments:
Environmental Health ��..
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