A40 193�
O
a
�
a
4
�
�
�
z
�
�Jun-'23=95 Ci2:16P- PE�'250N COUNTY HEALTH O • • � � P.02
.. ;.
_ �._
' 5e�tv.ices Requested: : '
_ Impravements Permit (Establishcd/Recardeci Lot) _ Reinspcction af �xisting System (Loan Clasiit
itnprovements F'ermit (Unrecc�rded Lot) „_ Repair/Replace existing Septic System
Irttprovements Pertttit (Mobile Home Replace) s� pertt�it for New We.11
Improvetnents Permit (Addition) Replace Existing WeU �
,,
Water S�iinple to be Cblleicte�l:
. ,_ _. .
� Baeteria �� Chc►nical�_�petroleum ._ Pesticide _ Lead
l. F'ennit re.yuested by: 7. Dimensi�ns or Proposcci Structure:
awnerlprospective owner/agcnt: ���'�ST�� f1�CETi Width: _� iv
Address: lS 1 CLG-�+'F�-►.i � L�,-�' __ Depth: �`f
Rtr� ��I� � � _r' � -, �--� '�
tne Phone #:�l_o - �°l'1 � 3 �t �
siness Pt�onc #:
8. What type (if any, additions, expansivns, or
repl�cement is anticipated tc� lhe sttlicture or facility
that this sewagc dispos�l tiystettl is intended to serve'?
. Name and addcess af current owner: 9. Wate.r supply t}•pe:
�E��� �� private Cv7�pi.�blic � c�mmtinity ❑ sPring Cl
�3 ����S �`����� Are any w�lls on adjoining property7Yes ❑ N� C�
��u'Q`���G"H �`�`�'C .�� �"� $ � If s�, icfentify location: i�-t- �S �i N l�.
_., _
1]escription: Lc�t si�e: i •
. Tax Map#: ,�=�D - '-,-�
Farcel#� i ti 3
Township: ��-T '�'� 1f��
� ni ir
, Directions tc� prc�Pecty: State Ruad # 14z �oad
�tmes, ete.
l�� , �- eu PL-�e-�ri�T[v-�J 'Q2. �..
_'�� TD �2.T DN N i�o t� ��
.� ( lS ��D�GvL l7�Sr4-L. T
lA. Type of stntcwre/f�cility: Propvsed: '�Existing: ❑
Type af dwelling:
House: C7 Mobile Home: C�Butiiness: L]
Type of b��siness: ND �1�
Number �,f Empl�yees: N��
Number c�F bedroott�s: 3
Garbage Disposal? Yes ❑ No [�
Basemcnt? Yes ❑ No C�'f sc�, # �f basernent fixwres:
G. Number of occupants or peoplc to he 5erved:
CLEAKLY S'�'AKE ALL GORN�RS UF T�E P�it)PF,RTY AND TH� COIZNFRS O�' ALL
PRQPQSEll STRUCI'URES.
1 hereby tnake application tc� the �'erspn COUtlty He�lth DepAxttrieltt for a site evali�aticm for tf}e on-sitc
sewa�e disposai system for thc above de�cribcd prc�Perty. I agree th�t the ccmtents vf this arPlicaticm are true
and represent ttie tnaximum facilitics tc> he placed on the property, 1 undcrstand ifi the si�e is altcrcd c�r the
intencled use changes, the pe.rniit shall bec�me invaliel, a undcrstand that bcfnre an Imprc�vements Permit ean be
issued, I must present a survey plat of the property to the Health Uept. I undertitanci that in the event 1 havc nat
deliverecl u survey pl�tt of the propc�rty to the Hc�lth llePt. within 60 �)AYS after thc date �f thc e���luation of
the site by th� Health Dcpl., lhis applic�ticm 5hall bccorne void and all fees paicl forfeitcd.
0
s�g„
, 1�su`�,
C)wner or Authorized Agent
_... .. ..� I 1
� ,� i
�I
• i
• a
� _.. . . �
� A 0!+38
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERNIIT
Tax Map #� � Parcel # � �j
Zoning Township � '
Owner/Contractor ` �
Lo ation/Address ov� `
. �
Subdivision Name�.Q,�" Q4c�.n�t
, r.�yout
,
A i � w !�,�li! � � . _
�ti�
.
�
�3
Date d�— � 6 —
S.R`.'# ` .,Q.�.,�.°i
/'. j`r
�
i i �.3 4�0
� " k; �
,.
d �� R
„•
� s. �v. �i, �,, ��
�
so�
��� �J�
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area � LP�it..� Size of Tank_/d�-�-
SFD Mobile Home�_ Size of Pump Tank �/�-
Business # of Bedrooms .3 Nitrification Line �Op ',Y',� �
Max Depth Trenches ,
Yernut Void ai�er 60 months. Permit Void ifnot in compliance with zoning regulations.
Permits may be voided if site is altered or intended use changed.
Well and Septic Layout by GrJ.��Q,Q .�
Comments:
Date 9=� (-9'S- Installed by :��,` ',; Approved by �.r�� �9,�.�w,_
� . . •.��
0
Site Approved�
Well Head Approue
Grouting Approved
Comments:
WELL SYSTEM SPECIFICATIONS
Semi-Public Required Sla �c_�
Replacement Air Vent c-
Required Well LQ� � W� o�
G" ell Tag c,� , D,
��,A.
Date �_�,_?�. Installed by �_ �;�I��z��� So,�' Approved by �. �� �.n�2.,�1.�' q�N
This report is based in part on infortnation 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 tlus report that may have resu►ted from false or misleading
statemrnts provided to him in the application Neither Person County nor the environmental health specialist warrants that the septic tank system will
contim�e to function satisfadorily in the future or that the water supply will remain potable. c:\amipro�pemut.sam Ol/93 rev.1.0
ORIGINAL
�
�2te: . L � � l
(,��.vnei: �-1-
Location/Directions:
Subdivision �Name: .
D 'll' Contracior-
�
n
I'I:It:;uN �:���►IJ'1'Y I:IJ1��J'IWNMI�:I�'I'AI� III•.A1�'lll
T
W�LL LOG
S�2#
Lot #
� ri �g � � rnN�TRLTCTION -
WELL .... � �
Distance from Neazest Properry Line Distar►ce from�Source of
Pollution �
Total lllcp.th: � F�• Yicld: �� GPM Static Waccr I.,cvcl rt.
Water Bearing Zones: D.epth . __ —F�- _---Ft, �G
Casing: Depth: � From_ to Ft. Diameter: Tnches
TYPE: Steel � Galvanized Steel �r S -
Yf Steel, does owner approve: Yes NO-------- �nches
' Weigh�______:`1'����5� �• Height`Above Ground:_______
�.
Drive Shoe: Yes�. No _ . ____—=— !
. Were Problems Encountered in Setting the Casing? Yes______ No_____—
If "yes" give reason: Coricrete �
Grout: Type: Ncat _ Sand/�ement �
A,nnular: Space Width l �_�nches � �=..
Water in Annular Space: Yes _ No_
� Method: Pumped.:._ Pressure______., Poured �;
Depth: From � � � �� �
Materials Used: No. Bags Portland Cement______ �ei�t of 1�bag_.___lbs.
Xf mixture (sand, gravel; cuttings) • Ratio: to _ .
Il� plates: Yes � � No.,______. �
� 4 x 4 slab Yes_ ✓ No _
I HEREBY CERTIFY THAT THE ABOVE YNFORMr�'TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY•THE PERSON COUN'I'Y HEAL'rH DEPARTMEI�I'T'. �
� � . �j--Zy-qS
� .,
Signature oC C'n;�tr� ��,r t �,j<<;
�
�
�