A28 190ao
Amount paid 3%�--
tRecezpt .4t � �— p�S�3
' . �� 16 L `�
�mprovements Permit.(Established/Recorded Lot)
Improvements Permit (Unrecorded Lot)
l - Z�I -q�
� Date
_ Reinspection of Existing System (Loan Closing)
RepaidReplace existing Septic System
_ Improvements Permit (Mobile Home Replace) �rmit for New Well
Improvements Permi t ( A d d i t i o n) _ Re place Existin g Well
Y�- 2 .. ' i; ( Z' r`
C J ( . z f� � : Y y z � � � A � �. � ,-wa?C*Z . j� ti � .,�'w
�� _; - r ...� 3,- .- S 2- e�� Ue Collectecl� >�_ Y3
- ` t � ). «-.x-- � F rt .:�
� � ater Sampl ,� ,x > .. :.
. .< .� : �: .�;
�-:r ..Fi.: . �. .:,v .....v {.t�._�; .. r a�w.�.YS.... . .v.:...nn. . . .
� .::. �_ ...
Bacteria _ Chemical _ Petroleum _ Pesticide
1, permit requested by: .
owner/prospective owner/agent:
Address: ���2_�
� �
�
w
�,�, Home Phone #:�
Q usiness Phone #:
a
, 2. Name and ad�i
0
�
7. Dimensions �r Proposed Structure:
Width: �� . —
_ Lead
8. What type (if any, addi[ions, expansions, or I
replacement is anticipated to the structure or facility .
that this sewage disposal system is intended to serve?
N o.U�
of current owner: 9. Water supply ty�pe:
� �, , ' private ��public ❑ community ❑ spring ❑
� ' Are any wells on adjoining property?Yes ❑ No j�.
• „,y,,, , ,Uc „t77'/�_ If so, identify location:
Description: Lot size:
Tax Map#:____�_�
Parcel#: �fi.
Township: O l �� �
Directions to property: State Road #& Road
ames,�tc.
Number of occupants or people to be served: 2._
10. Type of structurelfacility: Proposed: �xisting: Q
Type of dwelli g:
House: Mobile Home: (� Business: ❑
Type of business: IUTA — i
Number of Employees:��— �
Number of bedrooms: �_ � i
Garbage Disgosal? Yes ❑ No G�
Basement? Yes ❑ No �?f so, # of basement fixtures �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PerS0I1 COUIIty Health Depal'tment for a site evaluation for the on-s�c F:
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 property. I understand if the site is altered or the
intended use changes, the permit shall become invalid. I understand tliat before an Improvements Permit can b
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have nat
delivered a survey plat 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.
�
¢
Z Si�ncc� Owner Authorized Agent
�ermit Issued ❑ Signature
Permit Denied ❑
Plat Observed ❑ - -
.
Date
r2�Y�` 4.. �'A Y£-C's�.:� r . � �,�s a: ��.o Y e .. .:,"t .»g:K `�I�RP�S;i � x- x r,���- AAEA ����;`�C +k.*gt: ,�a :3 �.;vm� a it "��-:11RF�� x�< '�:
wex Y'r:.k�bh x, r.,,F.Y..�`r .d.£Fl1CTORF$TfE �'ALUA.��,�-£i�s ...��,.•. a k .. .a::z .�...�k +van s�" �£ . ... . ix.,.,..:.?:. a ac«..,:, ,�'xFa.,:.€a.f 2r:.xr� . H�y,4 �3.L: �.,cr.�R .m . ..... , . �ffc+..'s-�#�3F,`4�:
1. SIDPE (%) S S S '"" S
PS PS PS PS
u. u u v
2. SOII.7'FX7IJREQ2-16INJ S S 5 S
(SANDY. LOAMY. CIAYEY. NOTE 2:1 CLJ1� PS PS pS ._ FS . -
' . U U U.-� • U-.. .
l. SOR.SiRUCil)RE(Ib361N.) S S S S _
(QaYEY SOiI.17 PS . PS PS PS --
U U U • U,
3. SOILDEPI7{ (IN.) S S S S
. PS PS PS , PS
U U U U
S. RESIRICLIVE HOR20NS (iN.) S S -. S•, . S- ,
(IMPERV10llS STRATA, ROCK) PS PS � PS PS �
__ . . .. v v u..•' _ . - v
6. SOILDRAINAGE/GROUNDWATER ' S S S S � .�
(FXtERNAi.k WTEANAL) PS PS PS PS
V U V V
7. SOII, PERMFABIIS[y . S S S S
(PF3tC0[AA770N RA1t7 PS �. PS PS • PS
. •`:?`:: - - .- .. . U U U U
E. AVAILABiESpACE .- S S S S.
PS PS PS PS
p U . U . V .
9. SlfE CLA$SiF1GT10N(SEE BEL04� . . . � _.
. .. . _
�` - - :•.:. . ' .. � � .
SOIL SFRTES : .� : : , . � ' • �
• S-SUITABLE PSPROVLS]ONALLYSUiTAOLE U-UNSURABLE •
KECOMMENDATIONS/COMMENTS: �
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, �ill
areas, wells, water bodies, slope pattems,�etc.� C:�AMIPRO�DOCS�APPSEC.S�IFWANCE.PC ..
• ; ,
0
\
�
a
w
�
a
►•
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT 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 # � ��
Owner/Contractor
T�12 O�o �
Subdivision Name
Parcel # l `� �
Township f� I�� e� 1-{� � l �
Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area ,S, p�-C' _ Size of Tank � ���Q, �.l�o.( ��.�Q,�P�
SFD � Mobile Home Size of Pump Tank N �,4.
Business # of Bedrooms�_ Nitrification Line (gZ ,� 1
Max Depth Trenches_�[ � i �
Permits may be voided if site is
Well and Septic L�v out by
Comments: ,JI 0 4�� 1�71
Date
ell Permit Paid
iividual �
Installed
Site Approved_�
Well Head Approved
Comments:
or intended
0
Approved by.
' WELL SYSTEM SPECIFICATIONS
_Semi-Public Required Slab C
Replacement Air Vent
/ Required Well Log
<< I�_ Well Tag
., � . -
Date i(— (�i R Installed by
Approved by
This report is based in part on information provided the hoi�fieowner 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 fatse or misleading statements provided to
him in the application. Neither Person County nor the environmental health
specialist warrants that the septic tank system will conti�ue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
3166
n
�
JENNIE 1P. �[ORR01�
90— Ts — 228
– —,
CO?'Lt�l CO'f'?rLe�"
�
,
.
. �
O
.
o�
;� ,
- � �
��
a �.-- - -
1 so9.e
1 �TO?"��
I
� � � • '09"�
�g 5a .
� �23.s8
.�
0
,�
J1s�N1'
90—
L7 .� L9
�a•ov
b� �'RAG'� A NG
� � 21.34 �lCRh'S R -��[AINI
� -. � .-� .
� - � �:� _ P�P�OSED �60'SAS�'lt�N�"
;;� -
�:;: -
•:.�;'
: �;
�
�'�
J�NNIE 1I. �ORR�1%
so- � - zz8
1 _
�_
Controt CarneT
Sg���3 �33'�
�
39s, p� .
� ,
. ,
� o %
�o �,
a� �• r �
� � �9 :c
'S c. : �`'• � �
= r �-
� � � N8��5�:��
� �
649, 8�,.
! rT4T��
�
/�� ,
1 N�9'50 09"E'
, b23. 68'
��
o�
�
� ��
;
,.
� J1SN1' �
90— i
�
�5, 00 � � L1C
�
Ir11 � �
c� 1 TRAC?' A
`� 21. S4 ACR�,'S RE�[AINING
�
� n nn s�n c� c� s� cn � �+ � c• z+ � i z+ a rrn
L� ;
l.'I;I,:;c►N (:�JI►N'I'}� I{fVVI.ltONP;:•:N'I'�il. 111iA1,7.'tl • • �
, . - ' ., IJI•:i.l. I.cic� � .
a �
l�a te: � _ ,� �. : � y >
Ownei-: -r'
� - �... — .
,_
L.oc�tion • • ` .
----- ..� r � .. ,
�Dzrc,c[zon.•, n ' S � ' . . . ......_...__ .
� - __.__. ---_ S�Z#� . . .
---_
r. ____.._----- . .. __.._._ . .............._�_ , .
� �:1��' � visa�,�� .Na,���c: ___ . � �
Drilling Cont�-act `1 �.e_� �%r,S -f-� r � . . _.__
°� - ---��.h.�. s-�-� �J. �. ./[.. . . . .-.--._r Lot ��
. --�(,�_,��._l..l...._,,..� .
----�
Disc• � 1�(:1_.[..('c�)Nti_I�tt(l�(��I �-
ance ,fxom Nc�u-cst l'ro�,crty 1..,i„c..,�..�. . - � .
Pollution _ �'�...�-�...._ lli::�:i,�cc �roln Source o�' �
Total �D �� �c.s
. ..��'� ' �'ic:lcl: . �
I'[.
Water$earin ---.../�_.._--- �'�'M ,St,ilic
g :�Lones: D� �1a. _ Waier Level
Casinn: ' P .. ra_L?. 1'►-.. '�
� �eptti: � From - %G.___�'I.--_._.._r[.--__�t. �
7'XPE: S[eel _�—���c>._..5� ._.__�'�- .Uian . .
`�{`'j-: ' lnches
X.f Siecl, does owncr a�> >l�ov�: Gtilv, ini-r.,c;u1 Stccl �
1 � �., `...._..
wC1�11[:� ",(�IIC�JiC�•,.. __ Nc),------�_ , . .
Dxive Shoc: X�s_ ..,._---,L�.I��c,ght��,(�ovc Gzound � .
, - "�.� Nc� - .:-_._,L_.�—_.___--'�'nche.sT:
Wc,rc �'roblcros Ejicot��ltcrctl iii Sc[tilt � �lc C:� •' y•i , .. ----=_
�C "ycs" �;ive rcasai: t, s�n,�. � cs_---_ No ,..
Grout: Type: Neat `���-----__...._ � _ ____._;:
.S:,i�cl/C'c:nlcnt ,� _._._ . . ;%=�...
A�uiular.�Spacc Wi��� -- _ ._ __-- Coricxete • . ....;�=���
a r � .3.... __ —� :..,;�.
W tc Ai�niil..tr Sjricc: �'c:;.. ..__ f,�chc1 � ' ;;,
Mc[11oc1: � I'w» x:c , � - _..._ ___--� ��..._---. �---' . ' . ..
llcptl�: I�rom I �- _._._ . : . 1 rc...:ur�:.....__. _....---.. 1'��t.trc�cl_ � � . . . • .
��1[C � "--L%--..._.. l�' . a.v____ I'(. ----------- � '.r:
z-ials Uscd: No. �j j ,1 �'o � .
X.f ' � � 1�• 1c1:lC4Cl CCIJl ....__ �. . '...'..
-�.D I�1 icc C s•�nd, grrivc:l, cut.[in;:ti) .. IZr�[ic�cnt_ Weig1it of.l�b�a� lbs�''
1 S: xC� .✓ .riO ----�-�- t� F'_"`-E--=-a;.�;�
_ �( I� �� �!4{i� �_ "'.' � .. . . . ..._ . • • .. • "T,
xCS _✓ Nc) .. • .iw
..
__ •• ;
__... _ � - ,:: ��z
__... _..... ._ _ _,,•��:
(----_..__� _ (�)li I 1.1.1 ��!(:� 1,(}��;__ .
I-��� ---...___--._._ ....�... ._...... . .
- ---.__.______�----______.__.__
_ 1`�c;rrnat�on llcscz�
----
,.
i ti-�..r
....
`_- � ' -•'--,�L_(�...._��p_r.. . �_. __--- -._... �
---�-- --� -- - _ �--��� �( s- ..r __--... .. ___
. c -;--�]�,.� , _ `'
... .._
_'_`�----
� . -� '9�_rd
/ � � . .. � _� _...._-
Z ��RE$Y CEI�TZFX Tf-I�AT'1'I-I -L'• �;�3(�V : �. ��
x�s WELL WAS CONS �'R UC"1'LL) �� �CN��UIZM�1"1'XON :
��RT� �gY•Tk1�.P�RSON C�U.N��y [�t1;njCO�ZD�CL Wj
.: .. .Tt r DLPn �;�rM �
.�
-� l,.,J. . �..� __. !��
.Si17�t:ilurc c�l�(,ot��i.tc:tc,r