A27 69I�ERSON COUNTY HEALTH DEPARTMEl`�1T •
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # ��,7 Parcel #
Zoning Townshin 1/ �'
Owner/Contractor /1 Go h, _SGc�7� l,1 �1►-� Date %��- c1.�
Location/
Subdivision Name � Lot# �('�
J:IYTf' � / 'V UF'N�,
C�30
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area 1��� Size of Tank a
SFD Mobile Home Size of Pump Tank _
Business # of Bedrooms- �,_ Nitriiication Line � n D > 3'
Max Depth Trenches �L �� _
Permit Void after 60 months. Permit V
Permits may be voided if site is
Well and Septic Layout by
Comments:
if not in compliance with zoning regulations.
�� Date Installed by Approved by,
� � z�° o �.id
� Well Permit Paid ❑ WELL SYSTEM SPECIFICATIONS
F�-� Individual Semi-Public Required Slab
Public Replacement Air Vent
Site Approved ,/ Required Well Log _
Well Head Approved Well Tag
Approved
Comments:
Date Installed by 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 provided ro him in the application. Neither Person Counry 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.1.0
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Permit (Established/Recorded Lot) �_ Reinspection of Existing System (Loan Closing)
Improvements Pernut (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
_ Bacteria
1. Permit requested by:
:ome Phone #:
usiness Phone #:
Repair/Replace existing Septic System
Permit for New Well
_ Replace Existing Well
_ Chemical � _ Petroleum
Name and address of current owner: _
G� i/r .., �� �� �- . �i� �--
S�
: Lot size: 1 Aer�
Tax Map#:4�� ��. ,
Parcel#: _� a �
Townshin: C� /. �-�– � / �ock�
Directions to property: State Road #& Road
ames, etc j � _ � � �
—
Number of occupants or people to be served:
_ Pesticide � _ Lead
. Dimensions or Proposed Structure:
Vidth:
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?
9. Water supply type:
private � public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No ❑
If so, identify location:
10. Type of structure/facility: Proposed: DExisting: ❑
�ype of dwelling:
� House: �'11�Iobile Home: ❑ Business: ❑
�'ype of business:
I�Tumber of Employees:
I�lumber of bedrooms: 31.� �'
Garbage Disposal? Yes ❑ No ❑
Basement? Yes ❑ NoL�If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
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 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., this application shall become void and all fees paid forfeited.
or Authorized Agent
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Permit Issued Lld Signature Date �"%3" �-�
Permit Denied ❑
Plat Observed
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1. SLOPE (Rr) S H'� g g S
S� r'S r PS � PS PS
J�D' U U U
2. SOII. TEXNRE (12-36IN.) S S S
(SANDY, L0.4A1Y, CLAYEY, NOTE 2:1 CLA1� S ��` PS PS PS
U U U
3. SOIL STRUCi[JRE (12-36IN.) S �+ S S S
(CLAYEY SOIL.S) �/S ' K� PS PS PS
U � U U U
3. SOiL DEP77-1(IN.) S S S S
P �`�6 �� PS PS PS
� U U U
5, RESTRICI7VE HORIZONS (PI.) S S S S
(LMPERVIOUS STRATA, ROCK) PS � PS PS PS
U � U U U
6. SOILDRAINAGFJGROUNDWATER S S S
(EXTERNAL $ INTERNAL) PS �.p PS PS PS
U U U
7. SOIL PERAfEAHILI7Y S S S
(PERCOLOA7ION RA'fE) P ��/�� PS PS PS
U '�"' U U U
S. AVAILABLE SPACE S S S
PS PS PS
U � U U U
9. SITECLASSIFlCA7i0N(SEEBELOW) �
SOIL SERIES
S•SUITABLE PS-PROViSIONALLYSUITADLE U-UNSUI'fABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include; Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.) C:WMIPRO�DOCSIAPPSEC.SM FWANCE.PC