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Improvements Permit (EstablishedlRecorded Lot) _ Reinspection of Existing System (Loan Closing)
Improvements Permit (Unrecorded Lot) _. Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) _ Permit for New Well
Improvements Permit (Addition) ._ Replace Existing Well
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Bacteria Chemical Petroleum _, Pesticide _ Lead
1. Permit requested by:
owner/prospective owner
ome Phone #:
usiness Phone #: SS2/�/r10
7. Dimensions or Proposed Structure:
Width: � ��
8. What type (if any, addi[ions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
Name and address of current owner: s�� �' 9. Water supply t}�pe: �
' private� public ❑ community ❑ spring ❑
, Are any wells on adjoining property?Yes ❑ No`�
If so, identify location: �
Description: Lot size: /. /5�
Tax Map##:
Parcel#:
Township: � u
. Directions to property: State Road #& Road
ames, etc.
. Number of occupants or people to t�e served: �_
10. Type of structurelfacility: Proposed:�lExisting: ❑ I
Type of dwelling:
House: ❑ Mobile Home:� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: 3
Garbage Disposal? Yes ❑ No
Basement? Yes ❑ Nq,� If 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 COunty Health 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 propercy. I understand if the site is altered or the
intended use changes, the permit shall become invalid. I understand that before an Improvements Pecmit can be
issued, I must present a survey plat of the property to the Health Dept. I unders[and that in the event I have not
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 ome v' and all fees paid forfeited.
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permit Issued L�'
Permit Denied �❑�,/
Plat Observed Lf�'
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Signature Date
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1. SLOPE (sF) S S S
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9. SI7ECLASSIF7CAT10N(SEEBELOV,� � ('
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SOII, SERfES
SSUITABIE PSPROVLSIONALLYSUILABLE U-UNtSUITABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property ]ines, roads, streams, gullies, wet areas, fill
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B 1054
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlV�'ROVEMENT PERNIIT
Not �'or waste water system construction. No permit(s) for Construction Location or
Reiocation Activity shall6e issued until Authorization for waste water system construction
has been issued.
Tax Map #_� � 9 Parcel # � ,���„
Zoning Township r�s v �a y�
Owner/Contractor ''' , 7 Date � �- y � _
Location/Address
Subdivision Name
Lot#
S.R.
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area f � RCs�Ps Size of Tank /QQQ �..�`e�Ts
SFD Mobile Home Size of Pump Tank nir �
Business # of Bedrooms Nitrification Line �{0�7C 3�
Max Depth Trenches ��
Permits may be voided if site is altered or
Well and Septic Layout by /
Comments:
Date �-z -�](� Installed by ,JCti t�. n ci�t'f�m Approved by
y-� 4��6�
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 _Li
Grouting Approved ��
Comments:
Date S`- � � �j L
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 speciaiist 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
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: IMPROVEMENT PERMIT #: Q/D.S
TAX MAP #: PARCEL #:
OWNER/OWNER'S REPRESENTATIVE: ��t ' a vQI � e �en..4'�rV
LOCATION/ADDRESS:
SUBDIVISION N�1ME: !c1 I � ( � � A. t� � �'►
SECTION OR BLOCK:
AUTHORIZATION FOR CONSTRU�,TION ISSUED BY:
AUTHORIZATION CONDITIONS
LOT #:
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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 Pernut # 8/p 5 . 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 pernuts.
4. Conditions:
Person Requesting:
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SR 1164 60' R/W
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Owner: � � ��
Location/Directions:
Subdivision N�vne:
Drilling Contractor: _
PERSON COUNTY ENVIRONMENTAL HEALTH
_ _ WELL... LOG . . • _ : : - —
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WELL CONSTRUCTION
Distance from Nearest Property Line iG�` Distance from Source of
Pollution IGG � -
Total Dep.th: � Ft. Yield:�S GPM Static Water Level d J Ft.
Water Bearing Zones: Depth _�'3 Ft.�_Ft Ft� Ft.
Casing: Depth: From�_to�?�Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel �
If Steel, does owner approve: Yes No
Weight: Thickness:./8� Height Above Ground: /�/ Inches
Drive Shoe: Yes � No -
Were Problems Encountered in Setting the Casing? Yes No Y �
If "yes" give reason:
Grout: Type: Neat Sand/Cement :� Coricrete
Annular Space Width Inches
Water in Annular Space: Yes No
_ Method: Pumped - Pressure Fo � ed �✓ � �
Depth: Fr�m O �o � o 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 i�VELL WAS CONSTRUCTED 1N ACCORDA.NCE WITH REGULATIONS SET
FORTH BY-THE PERSON CO'Ji�'I'Y HEALTH DEPARTMENT.
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Signature of Contractor Datc