A28 177�Q,�,UO
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APPLICATION �+OR SERVICF.S
Impro`vements Permit. (EstablishedlRecorded Lot)
ImpFovements Permit (Unrecorded Lot)
ITnprovements Permit (Mobile Home Replace)
Improvements Permit (Addition)
I�-JI-`l �
Reinspection of Existing System (Loan Closing)
Repair/Replace existing Septic System
Permit for New Well
,_ Replace Existing Well
1, permit requested by: .
owner/prospective owner/agent• �2��-� �aw�
Address: ZZ 3 �'�r��,� �(n
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ome Phone #: S�i�7� � �� �
usiness Phone #: �S�`i -`� � � 3
. Name and address of:current owner:
�FLLI.� L. � sJ
7. Dimensions,or Proposed Structure:
Width: /��.
Property Description: Lot size:
Tax Map#:
Parcel#: . - . _ �
Township: -
Directions to propercy: State Road #& Road
ames,�tc.
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8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
tha� this sewage disposal system is intended to serve?
9. Water, supply t}•pe:
private� ,public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes� No �.
If so, identify location:
10. Type of structure/facility: Proposed: �Existing: Q
Type of dwelling:
House:C� Mobile Home:� Business: ❑ �
Type of business:
Number of Employees:
Number of bedrooms: ___,�_—
Garbage Disposal? Yes ❑ No i�
Basement? Yes ❑ No� If so, # of basement fixtures:
6. Numbec of occupants or people [o be served: .�._
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES•
I hereby make application to the Pet'SOI1 County Health Departme onients of this appli� tion ahe �e ite
sewage disposal system for the above described property. I agree that t
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 pla[ 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.
.�a� /� '�t /�!���
SiQncc� Owner or Auj1% ' ed Agent
Permit Issued ❑ Signature Date �Z� ��- %� - , ,.
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RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
' areas, wells, water bodies, slope patterns� CtC.� C:V�MIPRO�DOCSv1PPSEC.S�1 FWnNCE.PC
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PERSON COUNTY HEALTH DEPARTMEN'I'
,_ . WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
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1420
� Not for waste water system construction. No percnit(s) for Construction Location or .
Relocation Activity shall be issued until Authorization for waste water system construction' �
has been issued. -
Tax Map # � � b
Owner/Contractor
Location/Address
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Parcel # 1 � �
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'��/�►°P�,� o�� '�.
Lot#
SEWAGE SYSTEM SPECIFICATION3
E�epair Lot Area
SFD Mobile Home
Business # of Bedrooms�___.
Permits may be voided if site is altered
Well and Septic Layout by
Comments:
Date �Z -
ell Permit Paid
Size of Tank_�
5ize of Pump Tank
Nitrification Line_
Max Depth Trenches
,
Installed by ' Approved by
4a� - t ��-a
WELL SYSTEM SPECIFICATIONS
Semi-Public Required Slab
Re lacement Air Vent
te Approved Required Well Log _
ell Head Approved Well Tag
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Date
This report is based in part on information provided the homeowner or nisiner
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
ING _60' ACCESS EASEME �
:_�.____-__ NT ,.
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24B.10' /
N87'S5'12"W S87•55��2„E / �
_ MP 61.43' MP � .
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9 � 86-4 � �o �/
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• --�, � o � PROPOSED 50'
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N28'17'21"E � Ng /
43.43 j
25.00'
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/ IS '. 213'.59! E
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� � LOT TOTAL
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25.00'
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214.57
lOT TOTAL
N86'52�26'�W
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IS
S86•gZ�26„E
900,g�,
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Feb-12-9� 07c58A Barnette W�ll Co_ 910 599 0015
. YCHJVN I:UUt�lY tNYiKUttY�C1YIRL H�AL�1'!i
WELL LOG
Date:�lf � � � `
Qwner.^, Cr�g� . i � SR#
I,a�at�an�Directzons: �
' .c�i �t c�-� �"1L c.� ��-�Esr�-Y. _ ____
Subdivision I�Tarne:
Drilling C4ntractor:
�.,ot # - -
Distance frorn Nearest �'roperty Line �o'�- Distance from Source of
Pal}utivn lc7o '� `
Total Depth: t�o Ft� Yield:�.r GPM Static Water Lev�I as— Ft.
�aEe� $eari.ng Zones: DepEh �_Ft. S� F� I o�' Ft. Ft.
�asing: L7epth: From U to � Ft. �}iameter:_ ____ __ Inches
T�PE: Steel Galvani�ed Steel �--
�f Steel, does owner approu�: Yes I�Ia
� �'Veight� Thi�kne�s_ I�'�' Height��ibov� G�ot�nd:�Inches
Drive Shoe: Yes r� No _
l��ere Prablems Encountered in Setcing the Casing? Y�s Na—
�f "yes" give r�son:
Grout: Type: Neat SandJCcment --• Concrete
A.rmular Space Width �ches
Water in Annular Space: Yes Nc�
- - M�thod: Pwnped . . Pr�sure Pourzd .,•� - - -
I�epth: Frarn a *o � �t. -
IVlatenals Used: No. $ags Portlanc3 Cement Wei�ht of .1 bag_lbs.
if mixtuie ($and, grav�l, cuuings) - Ratio: t€�
II� Plates: Yes .� No � �
4 x� s�ab Yes � h(o
IHEREB�CERTIFYTHATTHE.AB4VEINFQRM�3TIOI�tISCQRRECi AND'l'HAT
THIS WE�L WAS CC�I`7STRLTCTED IN ACCQRDAI�CE WIT� RE�'�t,ATI�NS SEi'
�ORTH BY THE PERSO�I �^vL'ivT�' HEAI TH DEPARTIviEi�i�'.
,
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Signztur� of C��tractar D<���