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Improvements Permit (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing)
Improvements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) _._. Permit for New Well
Improvements Permit (Addition) _ Replace Existing Well
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> f- VYater Sample to be CoYlecfed
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_ Bacteria Chemical _. Petroleum _ Pesticide ._._ Lead
1. Permit requested by:
owner/prospective own�
7. Dimensions or Proposed Structure:
Width: �/6'
Depth: . 7 ' -
��- 2��3 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?
ome Phone #: �t %o ' S�i�' ���3
usiness Phone #: �(ld- �7-S�
Name and address of current owner:
W LG LC.G -
� i �l c.�.s� �LfLc�wO �oh�iy �
. Property Description: Lot size: �S 3s� s
. Tax Map#: /-� - Z 7
Parcel#: �� �`�' ��
Township: ort�� ��lt =
�. Directions to property: State Road #& Road
ames, etc.
r'o S -rn�•4- P...cP •
ntmuPc,cLtl.�p lfii�s-
� cl c���� {acF�
, Number of occuF
!�2o x S ►'►'I � I £ s (�.cs2_c�.
=�(L4-r�ct�' (�2t�s' —
-�,<- t.�91� vFQ�tc,u.�. �,
ts or people to be served:�{-�
9. Water supply t}•pe:
private�- public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes`f� No ❑
If so, identify location:
10. Type of structurelfacility: Proposed:�Existing: ❑
Type of dwelling:
House: �'Mobile Home: ❑ Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: 3
Garbage Disposal? Yes ❑ No (�
Basement? Yes ❑ No If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
'PROP4SED STRUCTURES.
I hereby make application to the Pe]rsOri COunty Health Departmerit 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 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., [his application shall become void and all fees paid forfeited.
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Permit Issued �
Permit Denied ❑
Plat Observed�
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Signature f.'�./��i����� Date /��`z����_
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1. SLOPE (%) S S S S
' PS PS
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2. SOII.TF�:7UAE(12•36IN.) S S S S
(SANDY. LOAMY. CCAYEY. NOTE 2:1 �L4Y) � r G U U U U
3. son ���� � ��.36 �;�.� S 6 k s s s s
(MYEY SOILS) � ps
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5. RESiRIC71VEHORIZONS(M.) i� `�� S S S S
(A4PERVlOUSSTRATA,ROCK) 5 6 � es Ps
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6. SOII.DRAINAGFJGROUNDWATER S S S S
(EXTERNAL& LVTERNAL) � I�� , S C,p PS PS
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7. SOQ. PERMF�IBIL7iY S S S S
(PERCOLOATION RAT� 03 � PS
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8. AVAILABLESPACE S S_ S S
� PS PS
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9. SiIECLASSiFtCATION(SEESELOW)
SOIL SERfES
S•SUITABLE PSPROVISIONALLYSIJiTABLE U-UNSUITABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
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g 2009
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERNIIT
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 # � — 01. '7 Parcel # �'�
._ . ...--- —'-'-- ,�c n _ 6 _ , � _�i� il
Owner/Contractor
Location/Address
ame
)r�-i�.-i�7
�-- S.R.#
Lot# �
Permits may be voided if site is
Well and Septic Layout by �1,
Comments:
or intended use changed.
Date /- a a-�1 �' Installed by ��2� �'A-�%r- Approved by LrJ.��P �.�-�-v,�,..,
Well Permif Paid
Individual �
Site Approved !�'
Well Head Approved,
Grouting Approved a
Comments:
� I Date
WELL SYSTEM SPECIFICATIONS
Semi-Public Required Slab 77`
Replacement Air Vent - -
Required Well Log ✓
7. Cj Well Tag � C� •�-�- �!
S-//- 9R-/�6v. p.
Installed by
S Approved by
This report is based in part on information provided the hKmeowner 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 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\permit.sam Ol/95 rev.l.l
!
P�RSON COUNTY ENV�RONMENTA,L.HLALTH
WELL LOG
Date;�(�►J 13 Q� G p . SR# .
Owner:
Location/Directions: - _ •
L�t ��_
Subdi�����on N�ne: TN �
Drilling Contractor: �a w�� M S
yyELL CONSTRUCTION_
Distancc from Ncarest Properry Linc
D�stance from Source of
Pollution 2O
Total Dep:�3-�: ,_... Ft. Yield•
Water Bearing Zones: Depth Ft�
Casing:
TYPE:
Grout:
GPM Sta.tic Water Level�_Ft.
Depth: From �_Lo �-�--, �. Diame �
Steel � Galvanized Steel
If Steel, does owner approve: ;es Height Above Ground: Inches
Weight: Ttuckness. , �
Drivc Shoe: Ycs No _ � — �
Were Problems Encountercd in Setting the Casing? Yes No
;f "ycs" give re:isor�: Coricrete
Type: Neat Sand/Cc:ment -
Aruiular� Space Width � Z. Inches
Water in Annular Space: Yes - N� Poured ��
Method: Pumped Pressure
Depth: From � to 2.� Ft.
Materials Used: No. Bags Porcland Cement________ Weight of .1 bag______lbs.
to
If mixture (sand, gravel; cuttings) - Ratio: .
TD Platcs: Ycs '� _ No _
a Y a clah Yes ✓_ No
I HEREBY CERTIFY THAT THE ABOVE INFORMr�TIO1N�TTH REGU ATINONS SET
THIS WELL WAS CONSTRUCTED IN ACCORDANCE
FOR'TH BY•THE PERSON COUNTY HEALTH DEPARTMENT.
. �r���
Signat�ire of Contract � Datc
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