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A29 161�� t`�`°v�.►�9?-, . .. iZe �s,..,�s,�. --.�- _ C�=� �-�.3-�� Permit. (Established/Recorded Lot) �_. Reinspection of Existing System (Loan Closing) ImpFovements Permit (Unrecorded Lot) improvements Permit (Mobile Home Replace) Repair/Replace existing Septic System �rmit for New Well Improvements Permit (Addition) I Replace Existing Well � 1. Permit requested by: . � z � :ome Phone #: usiness Phone #: � - %yD(� Name and addre&s of,current owner: Tax Map#; Parcel#: _ Township: . Dimensions or Proposed Structure: Vidth:�_— 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? 9. Water supply ty pe: privat�j� public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ N� If so, identify location: Lot size: ��'G � Directions to property: State Road #& Road Number of occupants or people to be served: 10. Type of structurelfacility: Proposed: C1Existing: Q� Type of dwelling: House: � Mobile Home�Business: ❑ Type of business: Number of Employees: Number of bedrooms: Garbage Disposal? Yes ❑ N easement? Yes❑ NoL71f so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the PersOn COUI1ty Health Depat'tment 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 property. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand tha bef r an Improvements Permit can be issued, I must present a survey plat of the property to the H h Dept u er tand that in the event I have not delivered a survey plat of the property to the Health De .'thin 6 A a er the date of the evaluation of the site by the Health Dept., this application shall be� void a all� es aid forfeited. Owner or A�oriz,�a Agent P ermit Issued l.�' Permit Denied ❑ Plat Observed ��' Signature Date �"-� �� . . , -� . ,' �. _. -- � l�� - � � �� w�� -�� . � S� ,. f n s� �� .2 `' . �� - _ _ �,��_. �� RECOMMENDATIONS/COMMENTS: SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, iill areas, wells, water bodies, slope patterns, etc.) C:UMIPRO�DOCSIAPPSEC.SMFWANCEPC _ --- N dr z� 4rw � � �� ,A�n � - I ? 9 t. od . �. ,. , �� _. - � .��'' � T29. G8 2g t o_o' . gt .� � _� 2�.03 =S�- �'T �t�.ar --- � --N Si' 2� , B 1221 PEiZSON COUNTY I��A�,'�'H D�I'�R'��'iV�L1�JT �x'E�.L r'�`v�D SEWAGE SITE, LOCATION IlVIl'ROVEMENT PERMIT ., � � NQt for waste water system construction. No permit(s) for Construction Location or �delocation Activity shall be issued until Authorization for waste water system construction , has been issued. � � W V � a Tax Map # �� Parcel # Zoning . Township ,' ,' Owner/Con..,� actor � ry� 1��---�- Date�.3- � l„ Location/Address ��i S �� 5�2�- (/(�Z ..� Si2,� ,[��, � -�,o /�l�Y;-��.,_y�,Z�! ri V� � ly� oh r� d o�'F S.R.# �/�, �_ Subdivision Name . Lot# SEWAGE SYSTEM SPECIFICATIONS Lot Area S Size of Tank Mobile Home Size of Pump Tank r� �� # of Bedrooms�_ Nitrification Line Max Depth Trenche . � Permits may be voided if site is altered or Well and Septic Layout by Comments: Date �- Installed by - r - � Approved by. Well Permit Paid WELL SYSTEM SPECIFICATIONS Individual_�Semi-Public Required Slab Public Re lacement Air Vent Site Approved � Required Well Log _ Well Head Approved Well Tag Grouting Approved j�� Comments: Date Tnstalled by. Approved by, —/�-S � /c�o�x6� 2 (�G� � l�;�� "�-.�' � 1 0.1� . , �� e S` �' �` �/ � 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 result�d 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 AUTHORIZATION FOR WASTEWATER SYSTEM CONST&UCTION ,• (Void si�y (60) months from date of issuance) DATE: U� 3 J/(� IlVIPROVEMENT PERNIIT #: � � I TAX MAP #: PARCEL #: OWNER/OWNER'S REPRESENTATIVE: �n'I � � LOCATION/ADDRESS: � � .� S/� � i��2 � S�� //,�.3 � ,/�%�UYY�c,�► —%%c.z�P D�r��v� %�� , �7� �� SUBDIVISION NAME: SECTION OR BLOCK: AUTHORIZATION FOR ISSUED BY: AUTHORIZATION CONDITIONS LOT #: 1. The Wastewater system construction and installation must meet all of the conditions of the attached site plan and specifications as set forth in Improvements Permit #�/2 Z/. The construction and installation must also meet all applicable rules and laws. 2. No portion of the Wastewater system shall be covered or placed into use until inspected and approved by the Person County Health Department. 3. Any alterations in site or soil conditions (including structure locations) or modification in use, design wastewater flow, or wastewater characteristics as specified in the associated improvement permit and application, may void this authorization and associated permits. 4. Conditions: Person Requesting: „��u�� e�� (� /�`i � r� Vs�d 1 o� e� PERSON COUNTY ENVIRONMENTAL HEALTH PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Map #: �Z� P�,� r� � Zoning Township APPiican� /\� �L/ '� Y V 1 �Y V t l� I U I l�V V ��/ 1, J 1�� 1�� "' `�Y I Locadon: � � / V � Y V v`'t �( - / i � 1 �� 7 y,� ( �l/ � �1/ I Subdivision• Section• Lot 1 v�G Gl��GI� �� Wefl Permit T e of Water Su i: � Individual Community ✓ Public ReQuirements• Site Approved by ✓ /�� - Grouting Approved by Well Log Well Tag Air Vent Hose Bib Concrete Slab _ Well Driller• _ Well Approved By: Date: **See Attached Site Sketch** y�'Wells must be 10 feet from property lines. �Wells must be 100 feet from septic systems. .�Wells must be at least 25 feet from any building foundation. I1� �O l�e �� v'o,W� �r�de��Y�'�r� 9as t�� Other conditions: PCHD, rev. 11/29/99 � � ? 29 . G8 .' . 8' .� u� _� z�.o� . �. '� . ., ... �� 1 I"� q, wor+c�r '�a ' L �� t�.ar --- _.-- N 8,�` 2 � . PERSON COUNTY ENVIRONMENTAL HEALTH � . • r WELL LOG Date: y � � �� ' Owner: :�. f}��r; A ��T � SR# Location/Directions: Q/iL1r�� /n.r /] � ' . Subdivision I�`ame: Lot # Drilling Contractor: ��.•Th ��rr� � WELL CONSTRUCTTON Distance from Nearest Property Line Distance from Source of ►. Pollution �t/� - Total.Dep.th:�/ d Ft. Yield: 2 D GPM Static Water Level 2 6 Ft. Water Bearing Zones: Depth t�5 Ft. F� � F� �t. Casing: Depth: From �5 to �l2 Ft. Diameter: 6%N Inches TYPE: Steel � Galvanized Steel � If Steel, does owner approve: Yes No � Weight: � Thickness:.i�� Height�Above Ground: /'�'� Inches Drive Shoe: Yes_J� No ' - i Were Problems Encountered in Setting the Casing? Yes No� Grout: If "yes" give r�ason: Type: Neat SandJCement � Concrete Annular. Space Width / � Inches Water in Annular Space: Yes No,�_ Method: Pumped . _ . Pressure . Poured � . _ . . Depth: From � io 2� Ft. � � MateriaLs Used: No. Bags Portland Cement 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 CO'Ji�ITY HEALTH DEPARTMENT. Signature of Contractor Datc A Itcation Date• � �a � � � � Amaunt Paid• � S � DD Receiot #: � Person Countv Health Deaartment Environmental Health Section APPLICATION FOR SERVICES Tax Maa #• Parcel #: � 1) Permit requested by: Owner/agentlprospective owner)�.�` ,� � �� ti Home Phone�3v�) � Q g� Address: — ��..1/ Business PhoneL��c�`�'`i5 a-S� �,,,,cQ,.�� n..L� . �.��-�'� 2) Name and address of cun�ent owner �: rtis ��4, � 1a-r-`� � n L. s '��n� � �cl� n-� ��1 � v�7 s- � '� 3) Property Descrlption: �ot srze: Township: Directions to the property (inc�di� road names and numbers): �"J it/ � i> >', �� 4) Proposed Use and Structure Descriptton: answer each of the following questions: a) Proposed O, Existing � b) Stick Built ❑, Modular 0, Single Wide �, Double Wde ❑ c) Number of Bedrooms: � d) Number of occupants or people to be served: e) Basement: Yes �, No � If yes, # of basement fixtures: � Garbage Disposal: Yes �, No ❑ g� Dimensions of Proposed Structure: Width: Depth: 5) Water Supply Type: Private 0(new 0 or existing ❑), Public �, Community �, Spring 0 Are any wells on adjoining property? Yes ❑ No ❑ If yes, location 6) Please Indicate Deslred System Type: (systems can be ranked in order of your preference) _Conventional Modified Conventional _ Altemative _Innovative Other (specify): CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY. STAKE THE CORNERS OF ALL PROPOSED STRUCTURES. PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLlCATION I hereby make application to the Person Counry Heaith 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 property. I understand if the site is aRered or the intended use changes, the permit shail become invalid. l understand that as applicant, I am responsible for identifying and marking property lines, comers and making the site accessibie for the personnel of the Person Courrty Health partment to condud their evaluations. i understand that I am responsible for notifying the Health Dep rtme ' property con s any we s as designated by the Army Corps of Engineers. - �a� � er or Rep sentative . Date PCHD. rev.10/12/99 �/� Application #: Tax Map #: Parcet #: Person County Health Departrnent Environmental Health Section SITE SKETCH � �i�� Cor,�v►-fr�.� � �-f-�I � .. l � �� , �PGI Applicant's Name �1/j/l,{,� SubdivisioNSection/Lot# �I�/�.'I _� I.%J/L.�� . �� ,i . -. - �.- �. - System components represent approzimate contours only. The conlractor must flag the system Scale: �1�'�"� PCHD, rev. 10/�i?J99