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Permit. (Established/Recorded Lot) �_ Re
ion of Existing System (Loan Closing)
ImpFovements Permit (Unrecorded Lot) I_ Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) _ Permit for New Well
Improvements Pecmit (Addition) _ Replace Existing Well
' ,��Yater Sample to be,Collected:,, "
_ ; �:: ; .
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_ Bacteria _ Chemical _ Petroleum _ Pesticide
1. Permit requested by: �^'ud°O ° D. ��'�� 7. Dimensions or Proposed Structure:
�wner/prospectnive owner/agent: ��13�1�� Width: �td;
ArirlrPcc• 1�1, /�% _ _ _ D@pt�l: �/ _
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ome Phone #: �il� �S"�- ��3 3
usiness Phone #:�lo S�i7 .S�S�4��
Name and address of current owner:
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c_ 2 7
intion: Lot size:
Tax Map#: /-�- 'Z7
Parcel#: sZ ,
Townshin: �.Yi Jr.—Il�l_ 1�.L��.n
_ Lead
-� 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?
' �,
Directions to property: State Road #& Road
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or people to be served:
9. Water supply type:
private �". public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes'� No [�.
�If so, identify location:
10. Type of stxucture/facility: Proposed: �Existing: Q
Type of dwelling:
House: � Mobile Home: L7 Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: 3 _
Garbage Disposal? Yes 0 0�
Basement? Yes ❑ No� 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 PeI'sOn 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 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 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 ihe 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.
Si�nec�`Owner or Authorized Agent
Permit Issued ❑ Signature Date ,_ �
.
Permit Denied ❑
Plat Observed ❑ �
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' �ACroxs-srre Ev�.urtnox .. . ;' ? . ° .?� t: ' ;- nRf
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1 S[APE (%) S S S S
PS PS PS PS
p U U U
2. SOILi'IX7URE(12-36IN.) S S S S
(SANDY. LOAMY. CIAYEY. NOTE 2:1 CLA1� PS PS PS . PS
U U U U
3. SOiL STRUCilIRE (12361N.) S S S S
(CLAYEY SOILS7 PS PS PS PS
U U U YH U
$ S S S
4. SOILDF�7}{(IN.) PS PS PS PS
v u u u
S. RESTRICTIVE HORiZONS (IN.) 5 S S S
(AIPERVIOUSSTRATA.ROCK) PS PS � pS
U U U U
6. SOiLDRAINAG&GROUNDWATER S S S S
(DCTERNAL & Q�TEANAL) PS PS PS PS
U U U U
7. SOILPERMEAB1UlY S S S S
(PERCOLOATION RATE) PS PS � ps
U U U U
8. AVAILABLESPACE S • S S � S
PS . PS � PS
U U V U
9. SifECUSSIFICATION(SEEBELOW)
SOILSEAIES
S•SUITADLE PSPROVLSIONALLY SUTtAIILE ll-UNSUITABLE
RECOMMENDATI ONS/COMMENTS :
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope pattems, eCC.� � C:�AMiPRO�DOCS�APPSEC.SM FINANCE.PC
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P�RSON COUNTY HEALTH DEPARTMENT
WELL AND ;iEWAGE SITE, LOCATION IlVV�ROVEMENT PERNIIT
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��'+Tot for waste water systein construction. No permit(s) for Construction Location or
Relocation Activity shall t�e issued untii Authorization for �vaste water system construction
has been issued.
Tax Map # t
Zoning
Owner/Contractor L,' n w � o� \�,
'Address
ision Name
Parcel # ,��� V O
Township (�l��vP ��,"l/
`� S P ; �� " DateT�� _�
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Perenits may be voided if site is altered
Well and Septic Layout by
Comments:
Date �- Z�E - 9 C� Installed by�
/ � n �1 `L��14 \�'"
Approved by.
Well Permit Paid �� WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab ►'�^�'�
Public R acement Air Vent � ,�
Site Approved Required Well Log _
Well Head Approved �"' Well Tag
Grouting Approved
Comments:
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 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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Owner. �
Location/Directions:
Subdivision Namc: ,
Drilling Contractor:
�ri
i�t:�t5utv uuuN'rv i�:ivv�.�wrvrir:rv i ni. �ir.n�. �,�
WEL•L I.OG
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SR#
Lot ��
K 1►�) � E�J 1 LL.l A M SO �1 .'L1�1 G.
WELL CONSTRUCTION
Distance f'rom Nearest Property Line Distance from Source of
Pollution
Total.Dep.th: Ft. Yield: � GPM Static Water Level Ft.
Water Bearing Zones: Depth __Ft. F�_F� ' Ft.�ches
C a s i n g: D e p t h: F r o m�_ t o�� Ft. Diameter:
TYPE: Steel � Galvanized Steel ✓
If Steel, does owner approve: Yes_______No
Weighe: Thickness:�.�.. Height Above Ground: Inches
Drive Shoe: Yes No
Were Problems Encountered in Setting the Casing? Yes No
I: "ycs" givc :cason:
Grout: Type: Neat _ Sand/Cement _ Concrete __
Annular' Space Width l�—�ches
Water in Aiuiular Space: Yes_______ No_
Ivlethod: Pumpcd__ Pressure -- — Roureci ✓ _.
Depth: From � to � Ft.
Materials Used: No. Bags Portland Cemcnt_ 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 IN ACCORDANCE WITH REGULATIONS SET
FORTH BY•THE PERSON COUNTY HEALTH DEPARTMENT.
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Signature of Contrac " llatc