A40 189-' I�erson County Health Department
Sewage System Improvements Permit
Date:3.���'This Permit Void After 3 Years
Owner: � @ � ���--��,<f
Location/D'uections:
Subdivision Name: r� , V�v� r� K �
Lot Size: f, �Jr� ,�. tv P Type of Dwelling:
Water Supply: Private: Public:
Semi Private: If not Private Tax Map#
Parcel # of Water Supply or Name of
Supplier#
Becirooms: � Gazbage Disposal
Basement Basement Fixtures
INFORMA N ER D BY ,��
$alllta[ja11: � , o er or repre:
Lot #
z
•. I!�'
REPAIR: REEVALUATION: � �
------- ----------------- �
Size of Septic Tank: �� gallons , �
Nitrification Line: �-Q� � X 3
Depth of Stone: 12 inches ✓"
Max Depth of Trenches•
OPERATIONAL PERMIT: yes no
Remarks•
Date Well Approved: WeL' should be 100 fL from any sewer system
BY Janitarian
Date Se e ys,�em p rov • �- -
BY anitarian
v CEK '�E OF CO LETION �
Contractor. �
------------ ---------- �
Sewage System location, installation, and protection must meet state and local �
regulations. Septic tanlc should be pumped out every 3 to 5 years and shall be
maintained by owner in such manner as not to create a public health hazard.
Septic tank and ni�ification line must be inspected and approved by a member of
the Person County Health DeparUnent before any portion of the installation is
covereci and put into use.
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
1
NOTE: Make sketch of installation showing lot
supplies, etc. Note special problems existing on lo
, t later date. Note location of water supplies o!
(1)
� _ r �r a � /
and shape, location of house, septic tanks, privies, water
� in measurements in order that installations may be located
�nt lots.
(2)