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nts Permit. (Fstablished/Recorded Lot)� ._ Reinspection of Existing System (Loan Closing)
Impxovements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
improvements Permit (Mobile Home Replace) _ ermit for New Well
Improvements Permit (Addition) _ Replace Existing Well
1. Permit requested by: . hw��'�- -�� S 7. Dimensions or Proposed Structure:
owner/prospective owner gen � o3�y �.�n�� Width: 3. � — .� ��a
Address: • ' DeP�h: ' Z _
P•t� ��–��'�'�= �''� 8. What type (if any, additions, expansions, or
� 7 Sj�. C'.� /�,�t replacement is anticipated to the structure or facility
�;,x c�,2� rU� 2`�,'� 3 that this sewage disposal system is intended to serve?
ome Phone #: � � o - ��� ' ��' 3 �
usiness Phone #: �Slo r�"1_- �.� .
z
Name and addreSs of,curnent owner:
/.�GL�'�' ,G�t�.-s _%�
- n - . -. .
c�l�o � c
Description: Lot size:
, Tax Mag#: /�-� - � `7 L.�t S�-
Parcel#: � �' SZ
�Township: C`��E�� ���I -
. Directions to property: State Road #& Road
iames;�tc.
'�� , c �,.., .. �„ n .�,. % �_t�i Ll I to �l l r u �
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9. Water supply type:
private � . public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes�l No [�.
If so, identify location:
10. Type of structurelfacility: Proposed: �Existing: Q I
Type of dwelling:
House: [�Mobile Home: C7 Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: 3
Garbage Disposal? Yes ❑ No �
�Basement? Yes ❑ No� If so, # of basement fixtures:
L6 Number 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 PersOn COunty Health Depat'tment for a site evaluation for the on-site
sewage disposal system for the above described properiy. I agree that the contents of this application are true
and represent the maximum facili[ies to be placed on the propercy. 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 pla[ of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the propecty 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.
�
.
Signc O ner or Authorized Agent
Permit Issued �
Permi[ Denied �❑ /
Plat Observed LY
Signature
1 Date J � � ( / �
, ' . ..�
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, s[reams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.) C:�AMIPRd�DOCS�APPSEC.SMFWANCEPC
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B 1442
PERSON COUNTY HEALTH DEPARTMEN'�'
WELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT PERMIT
-` Not":'or 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 # 2
Zoning Township f� i V e + i �
Owner/Contractor l_ t''� �.�� �, �,, es' Date �- � 9 7
Location/Address
S.R.#
Subdivision N�
SEWAGE SYSTEM SPECIFICATIONS
air Lot Area Size of Tank � �,
) Mobile Home Size of Pump Tank 1►�
iness #ofBedrooms�_ NitrificationLine �f�� i�3�
r.,;.�,� � Q�,.ree Max Depth Trenches 2���
Permits may be voided if site is altered or
Well and Septic Layout by
Comments:
��
Date I—�� Installed�y ?��G� -�'�-i-- ' Approved by G�.t%e� ��C,c-�-Y�.
� . Z _ �7 c, � � � �, .
eli Permit Paid [!�� I WELL
dividual��_S emi-Public
�blic � R cement
te Approved j
ell Head Approved�/�
....4inR Anr�rnvnii 1�f...l �. .�1...,i�.,.�/ 10/n-��a'Y�
Comments:
Required Slab �g C��p3 �Q�j
Air Vent 1/'
Required Well Log �'
Well Tag i�
Date//--I /—�'"7 Installed by��1V�u,� 1,,1;Il,an�5pa Approved by�v.�(� �,�,��,�,
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permi� The environmental
health specialist is not responsible for false or misleading in%rmation
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 resulted from 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 future or that the water supply will remain potable.
c:�amipro\permi�sam O1/95 rev.l.l
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PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date:��"`�;� � C� -r(�G�7 � . SR# S� ►�)
Owncr:
Location/Directions: . ,
Subdiv���on �Name: Lut �_
Drilling Contractor: �'� w�� �M � �
WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollution----� _
Total.Dep.th- : � Ft. Yield: GPM Static Water Level Ft.
Water Bea.*ing Zer.es: �eFth Ft._______F�- F�_��t.�ches
Casing: Deptti: � From__ b___— t–o�o 3 Ft. Diame � y
TYPE: Steel - Galvanized Steel
If Stecl, docs owncr approvc: Yes No
� Weight: �� Thickness: • I Hei;ht Above Ground:________ Inches t
Drive Shoe: Yes No � !
Were Problems Encountered in Setting the Casing? Yes No
;; "ycs" give rcason:
Grout: Type: Neat Sand%Cement ✓ Concrete
Annulat. Space Width 1 Z. Inches
Water in Annular Space: Yes No_
_ Method: Pumped � - Pressure_. Poured �_ � __._ ..
Depth: From O to 2.0 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
THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON COUNTY HEALTH DEPARTMENT.
. ,
' �-Q 9�
Signature of Contract � Datc
�
A lication Date: 1 "d -DO
. Atnount Paid: �
� ' • R�ceint #: � 0
�-X'�
Person CountY Health Department
Environmental Heaith Section
. APPLICATION FOR SERVICES
Tax Map #: /�� �
Parcel #: � �.
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED. CHANGED, OR THE SITE IS
ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID.
1) Permit requested by: (Owner/agent/prospective owner): :�� � ` � ` ��' � �� ,/
Home Phone: �- �a Address: f� 2-�j �,it D.tiTD � r, u/l/.;�} ,/� /a.,.0
Business Phone:_ �n �, l ,�. .2 �,
2) Name and address of current owner: %�� ���� ��' �, �=.e� �O
. -�-T -�- _ = rc,� ,,� � �C
11
3) PropertyDescription: �otsae:•���wnsn�ip.`�����
Directions to the property (Including road games and,numbers): � �
4) Proposed Use and Structure Description: answer each of the following questions:
a) Proposed O Existing �
b) Stick Builj,� Modular �, Single �de 0, Double Wide ❑
c) Number of Bedrooms: � d) Number of occupants or people to be served:
e) Basement: Yes ❑; No�if yes, # of basement fixtures:
����� � ,
3�3� �rz�r�� f� D�:
il s 2l� �10���
� � � �--�--.
v q
6'Y12i�G�
`-� I� f► VL! I C(�
fl Garbage Disposal: Yes �', No � c� , �1�
g) Dimensions of Proposed Structure: Width: � Depth: 3 d C� e�- 1�'bdM�O '�t l�L � V
5) Water Supply Type: Private�new 0 or existing ❑), Public �, Community �, Spring ❑ ���
Are any wells on adjoining property? Yes ❑ No � If yes, location +��
6) Please Indicate Desired System Type: (systems can be ranked in o�der of your preference) ���\
\"�
Conventional Modified Conventional Altemative Innovative
Other (specifyj:
CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION
I hereby make application to the Person County Health Department 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 pertnit shall become invalid. I understand
that as applicant, I am responsible for identifying and marking property lines, comers and making the site accessible for the
personnel of the Person County Health Department to conduct their evaluations. I understand that 1 am responsible for notifying the
Health Depa ment if m pro contai s ny wetlands as designated by the Army Corps of Engineers.
�� -- G '- a�
Owner or Legal epre ative Date
PCHD, rev. 10/12/99
Yerson County Health Department
Existing Sewage System Report For: Mobile Home Replacement `��"'
� �/ Addition
Requestee: t"1� � 1��1 �� �' UI/o �w1�2� Home Phone# ����
�py�{-� ��,�� �`�� Business# —
��DVd � l�/ 22,�%� 'rax t�ap# '�i
Location/Directions: � �� �� ��� �i" � �2� �
�.�-- r�f"����,t� �Vl ��°f, .� ����
Original Permit Located
Septic System Uesigned For: �-
ltesidential _�� Business Other (speci�y) _
# [3edrooms �_ # E�mployees Other �
Uate :Lnstalled ���—"I� Water supply
�
'Pype of System
L�
Nitritication Line Q�' ��)� _
Tank Size
. ✓
Certified Operator Required �,lYi
On site wasL-ewater disposal system showes no visually apparent
malfunction on �-i 2`b�
Yermission is granted to: � �
According to the attached site plan.�
• �%[i�r"I�l[I1`.TI•f[f�III>�i%/,l/.A1'E��LQ/�/�L/iL//��/I/�t�
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, 245, P. 601
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