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A28 187. ,. y � W � a B 3077 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMI'ROVEMENT 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 # �o� � Parcel #� � Zoning Township ' � � ► ` I Owner/Contractor`T'o,,� n� C/'��,�,,.v�-��i �',��{S Date g� 2-9 Location/Address �Q 5"�I�_ P� I a1 o�i� �ct t n► Qa� . T��. I n; �� IQ r��� - ' l L 5 � ; �_�{ ; Subdivision Name l n �h1n Lot# S.R.# SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area ,� 0� Size of Tank �� ' �� e SFD Mobile Home � Size of Pump Tank Business # of Bedrooms_� Nitrification Line �16T� `X3 � Max Depth Trenches � �� Permits may be voided if Well and Septic Layout by_ Comments: . � n,�.,�A aitered or i �� �y� .��I Ms� changed. . A n Date - -� Installed b}�'%�j((/�° Approved Well Permit Paid WELL SYSTEM SPECIFICATIONS Individual Semi-Public Required Sl ' Public Replacement Air Vent ' Site Approved� /U`- Required Well Lor Well Head Approved �iP� Well Tag . Grouting Approved �f ' J) + � .�� `� � J�J -/ Comments: � Date -� Installed by , Approved b This report is based in part on information provided the homeowner or his/her representative in the application submitted for tnis permit. The enviro�mental nealth 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 e�vironmental 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 �'00�48„E 27— � 5 N 1.63 W N ACRES r � ' n �5 IS S80'00'48"E 226.61� 4 1.31 ACRES S86'30'05"E 393.18' T07A� � IF 142.76' IS 80.00' IS .� ?� v �,� �P Z _ cs ,;- h� 3 � � N�355j,�S,�W IS / N7 �241�p��� 32.00' _� � � ��tih � . 3 / AXLE '� $ ���� 4� NS �� \ -' �- NS 54�' � ACRES ` � J _ ` �--� � r,F —�� � ` � � •�a "� ( 45.86' !F 34.91' �` IS '' v N � �y w (�, �,a�' _ _ \ NS � 32 . 00' o 0 i �� N� � � Q, � <n o `O : \ � ' RO/ ' '` ; � c,, IAP f� N ' � �� � / A � ' � . . . a o,• ' ARTHUR S. KATZ � � z �°i o'S1 � 00 �o D.B. 200, P. 864 � • o = \ \ m ACRES � � . � . � . � IF 54.60' 327.99' s IS cvl T,AI�..V' i S N87' 13' S4 "W — — — — — � � � ST � ►�� ,�. � jF ---- �--T��_ J? 0�� __-r � .3C'qIC' ��_ /� � � � NS ► .. _. ..._ / — �v� \ / _ �� �_ _ _ c a ' �o�� � T `�' �f �u� �� �;; �� � _ i �' �f � r /• � ��,t' � � /�`�� �# ���% .� '�� ��i c'�� j ; / � / : Cc ��.�� r � �Gb � �' f k.n ���s � �'tie�- fF�' �./� � � � � y � o yy ,�,� o4r.� : - DATED, THIS IS A %' RECOROATION. SALES CTATF �F N�RTFI f,AR�I. iNA " 0 • t�J N W 1 ` z _ 1, rt, ' 1 �� � W � ��U�� ' ��,�sl/ • �� � � .d : `�� _ `1' r-- .—, N �s � ACRES � ������ Ax�E ''Q � ��- X..9 .W . P� ..�D , 1 r' � 54.60' � IS r � �� �ii�"x�'� ak � - . � � • tJ . >� ���,.��� � ��t �� �`��*,., .� .. ..• tt�.i�� tt� : � s. � T > r 1iN,,�,,, i' �. �' , V � , +.r 8S� `;i t�-�`"' � . . •� � tiy:rMf{}�i' � �_' rf' I : 4 ! �F�.t, t r `� '(a. j�•� J s;;,��t�c j,�- " W W ,�`' �'� �'��,�T ,'ti , .� �0 .�' � � , � ~ i ��. �{ 7G J����� S . . , .�'� ���yj�''�3�� � � � . r � ~ `'`�' {�,r�.;f �?� ' � � . O .r�+,`aty�M �"64 � % Z '�L t ^� �' � � ` f `• �`• � ;: � ✓i� �� i + �' t' �.'� %, ;�t,� r{ ��:�,�g4�r,, �, �: � � `p `.,�y?vpv��'k tis�ta : ��t` � �,� ,� yf�•�fyy4., �. �„ 1+'4S ,� �t��'!t�{ f{ j. K . . .� ;�,�� ����} :: � � ,�Y9 ' : r: � � . � �.. � �� - � I S`��y ���k .; !f��i�y .� � , .. ' t �f � �Y'Ci�f1�Ki ti.• .,' � r ��� � � c ll � ;. ��, ' ' , �, 7 g• 2� � � " V.G:.`Q!. . N �� ,�� �� . 1 � ` ��.7 ��rr r 5 � . .� .. ` �,t�c � .: �tx � �R ••••�'��' � � � n1 ,J,," a�1r.��" .� �. �t.. �; ,ti ..,6sJla� ��'la� � '' r NF �x ���t,���,�; �� � � � r�; �:'*F,t��f��a� � � �� i ✓. 7 � � ` :��3 4 � �: 9 �1 �.� �� , , ' � d� 45 . 86' : •�.}��;t�� � � . ; :, �� ��, � � ' � ��.: � ? F; � �i'rr��k�g � (�,� � `� �,�'� � t �� .Kr��i� k ��. , � r . - ..'j ; fi'��-c ��,� ' ... � . .. t q p� �' .1� �liid k f . , � . , � t � a�� � 4 ��; � +, N , '`P �i r�ti,s��ii�;< U1 � ,,,}��� ;r �., .p �• ; , � � li� ..� '`,' �' r • � y� :ti. � � 7 . . _ . �� AF W �. i � � �� � �s � � � f � i� � e �. 0 0 � . �:j ;. ���:�j ���;. . ,.,..� rt1 s;,�,�,%�qY,����� � � �.,''� �fs���.� � t � ,,y �(�,� ����.Y'��`�� '. . w C ; A RE �=- ����� � a � � c �s � � e�.�� . i � s ,' '�rrt� r � ; . - 1 ', s ` � ti vPs��� , �az. j • �: t S . � L �L d��.L`s�i�ppp`� e. - - .' � � . ' � n •, itF �� � � � 1.�� � ' sV�fx i^,�� � �.i� ��^a^1 z! ����;5;�'� ' � �' a�i'+. st�i k� y - . . . .. : . .r'�.~ j� � `�4k, . . . .. . . ' . Date: � l 1 ��1 ' Owner. _� �����u Location/Directions: � b�..i-a- i� i� � �-i� � v ot Subdivision �Name: Drilling Contractor: _. _ ._ . . . _.__ __ ._ PERSON COUNTY ENVIitO21MENTAL HEALTH WELL LOG ' �T�l ,��`�"n5 ��, �J � I i- � o� 1`�-�. �� l�l�� �1�.:� � I � ,Q ,. i L� ►�1�1TT �I — .l-I T I i • ,� _ � SR# � - �.� � * �, '- Y4rY�, . -. a. ; ' �t��tl��' • , Distance from Nearest Properry Line �C� Distance from Source of Pollution (C� ` Total Dep.th: �� Ft. Yield:�_ GPM Static Water Level Z�-i Ft. Water Bearing Zones: Depth7�� _Ft. � F� � F�, �t. Casing: Depth: From � to�Ft. Diameter: Inches TYPE: Steel � Galvanized Steel / If Steel, does owner approve: Y�s No � Weight: � Thickness: /$k HeightAbove Ground: 6�i Inclies Drive Shoe: Yes ✓ No • Were Problems Encountered in Setting the Casing? Yes No ✓ II' "yes" gir•e r�ason: Grout: Type: Neat Sand/Cement ,/ Coricre[e Annular. Space Width Inches Water in Arulular Space; Yes No. _ .. Method: Pumped . . _ . �Pr�ssure � � Poured ✓ � �- �. � � • �; - : . Depth: From O. to ��� Ft. . � Materials Used: No. Bags Portland Cement Weight of .1 bag__lbs. If mixtuie (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 T�S WELL WAS CONSTRUCTED 1N ACCORDANCE WITH REGULATIONS SET FORTH BY�THE PERSO�I C�Ui�1TY HEALTH DEPARTMENT. � --� �--_ �S gnature of Contractor ace �