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Amount paid ��i� • �j'
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Improvements Pecmit.(EstablishedlRecorded Lot)
ImpFovements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
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Date
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Reinspection of Existing System (Loan Closing)
Repair/Replace existing Septic System
_ Pecmit for New Well
lace Existing Well
l. Permit requested by: .���,� '�,� y���s 7. Dimensions or Proposed Structure:
owner/prospective owner/agent: Width: 7�i
Address: a2 7!e_ ��IA A�- Depth: �y
° . What type (if any, additions, expansions, or
r placement is anticipated to the structure or facility
t at this se�vage disposal system is intended to serve?
Home Phone #: S� 9��q� �� ,U e
usiness Phone #: �59� �/3��� 6 _3 P��' �
2. Name and add ess of urren[ owner: 9. Water s y t}'pe:
rs private public ❑ community ❑ spring ❑
�f Are any wells on adjoining propecty?Yes.� No [�
_C . S'I 3 If so, identify location: ,�75 Gi�A� �'4�,e �.
3. Property Description: Lat size: S/� Ac�.as °'"' �'��� dc��s
. Tax Map#: �� 10. Type of struc[urelfacility: Proposed: �Existing: Q
Parcel#: I Type of dwelling:
Township: ��.t W� .�� House� Mobile Home: Q Business: ❑
5. Directions to property: State Road #& Road Type of business:
ames,�tc. Number of Employees:
S� 6 O Number of bedrooms: �_
C � Garbage Disposal? Yes ❑ No�
Basement? Yes ❑ No� If so, # of basement fixtures:
6. I�Iumber of occupants or people to be senred: �
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 pcoperty. I agree that tiie 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 pecmit 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 Depi. within 60 DAYS after the date oE ttie evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
� / � � ��. —
Signee��wner or Authorized Agent
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT
B 3155
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 # �`t" � 0
Zoning
Owner/Contractor ��, � ; n �pu
T nratinn/A�riracc I �52 \,/ �'� � �
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Subdivision Name
Parcel # � � �
Township �� ; �� 1�1 � � 1
i-4Gt �' `; 5 Date (� �.- q �j
�e_ �e �-E-� �-- �n,l TI �- C, I� � r I � �_
S.R.#
Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area a.�� Size of Tank � � � 41- �
SFD � Mobile Home Size of Pump Tank
Business # of Bedrooms •� Nitrification Line 53� 'X3'
---�— �, , �
Max Depth Trenches � $ -ao
Permits may be voided if �i
Well and Septic Layout by_
Comments: ,�4 ('�t,0�
�SC � �o �� c� �An�1s�
attered or inte.aded use changed. _„
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Well Permit Paid C� WELL SYSTEM SPECIFICATIONS
individual � Semi-Public Required Slab �/
Public Replacement Air Vent
Site Approved Required Well Log —- �
Well Head Approved Well Tag 1�
Grouting Approved - - �� �o5�e 6��b ✓
Comments:
DateJa`IO-9q Installed by����y�,o (,c�t� Cp, Approved
This report is based in part on information provided the h�meowner 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 ta�k 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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