A27 79oa
_AmcL�.�t pa�a lo�� ��3Q- �%
Receipt �i � t� Date
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1. permit requested by: .
owner/prospective owner/agent: ��
Address: • -
ome Phone #:
usiness Phone #: G�y .�l3�
7. Dimensions or Proposed Scructure:
,DU��l�X W idth: `'/ � �
� Depth: 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?
Name and address of current owner: 9. Water sup ly t}pe:
5,�.� G ' - private public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No [�
If so, identify location:
PropertY Description: Lot si
�g
. Tax Mag#: ,Q �'7
Parcel#: 7�
Township: C) F a V e la i L�_
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� 5. Directions to propercy: Sta[e Road #& Road
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10. Type of structure/facility: Froposed: �Existing: Q
Type of dwellin :
House: obile Home: L� Business: ❑
Type of business:
Number of Employees: .
Number of bedrooms: �
Garbage Disposal? Yes � No �
Basement? Yes❑ No��o, # of basement fixtures:
6 I�Iumber of occupants or people to be served• .,�_� �
CLEART;Y STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES•
I hereby make application to the Pet'SOn COutlty J3ealth Depai'tment for a site evaalualic tion ahe t�rueite
sewage disposal system for the above described property. I agree that the contents of th�s pp
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. wi�in 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become voitf and all fees paid forfeited.
s�
r or Authorized Agenl
permit Issued ❑
Permit. Denied O
Plat Observed ❑
Signature Date �' �� � ,
..,
'�� £ '�y�� x"� � �J�Ci'ORSSiiE E�!ALUA71Q2��, '''K� s �ai.�i.�:�.s.s 3fi'f � ' ..''i�+E »r � �:� �j��r�"f i',�'.°[ i4�, f;E�''��i. ,eax�,; y $tr<�`r.� � - ^�#',,m P;��^".'xx.".
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1. SLAPE (56) S S S
PS PS PS
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2. SOII.I'DCiURE (12-)61N.) • S �� S S S
(S+�NDY. LOAMY. C[J�YEY. NOl'E 2:1 C1.Al� , PS � � 1 1 PS PS PS .
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3. SOiLSiRUC'iLRE(12-161N.) S S S S '
(Q�YEYSOti,S) �_/1,✓L PS PS PS -
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PS � � PS �5 PS
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3. RESTRICIIVEHORRANS(iN.) S S • S•
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6. SOA.DRARJAGEJGROVNDwATER , S S S
(FJCiIItNA1.AQ:IFRNAI.) PS �o PS PS PS
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7. SOII.FfAbiFA811lTy S S S
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SOILSFRiEy • . �
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SStJiTADLE KTROVl170NALLYSUiTAIILE lltRtSUItADLE
1ZECOMMENDATI ONS/COMMENTS :
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns� C�C.� C:MMtPRO.DOCSAPP5EC.5�1 FlN/�NCEPC
B 1744
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
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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.
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Tax Map # ,,�� � Parcel #_
Zonin� Township
Owner/Contractor
Location/Address�
Subdivision Name
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Date c� - �j �
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Lot# 21�
SEWAGE SYSTEM SPECIFICATIONS
Etepair Lot Are�� �, ac,,•e
SFD Mobile Home
Business # of Bedrooms�_
Permits may be voided if site is altered
Well and Septic Layout by
Comments:
Date
ell Permit Paid
Installed by
Size of Tank 1
Size of Pump Tank_
Nitrification Line �
Max Depth Trenches
use
Approved by.
WELL SYSTEM SPECIFICATIONS
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idividual��Semi-Public Required Slab
ublic Replacement Air Vent �1
ite Approved Required Well Log
�ell Head Approved Well Tag __�
�routing Approved �
,�c�v tc7 yGn.���
Comments: �C7� t o- —q _
Date �- - Installed byJ�,� ��s�on f,,)t�� Approved by.
This report is based in part on i�formation 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 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 O1/95 rev.l.l �
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SITE PLAN
- SANDRA DUNKLEY
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