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Improvements Permit (EstablishedJRecorded Lot) _ Reinspection of Existing System an Closing)
Improvements Permit (Unrecorded Lot) _ RepaidReplace exis[ing Septic System
Improvements Permit (Mobile Home Replace) _ ermit for New Well
Improvements Permit (Addition) _ Replace Existing Well
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Bacteria _ Chemical Petroleum _ Pesticide _ Lead
l. Permit requested by: 7. Dimensions or Proposed Structure:
�wner/prospective owner/agent: � � ` Width:
� aa..e��. C.:_._ _ _ 1'r� �..�t- /./,,..�,: �7�� �lu„�� Denth: � �
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�� S �� V 8. What type (if any, additions, expansions, or
�' replacement is anticipated to the structure or facility
e�T �'n s�, that this sewage disposal system is intended to serve?
ome Phone #: �
usiness Phone #: � y� /�lX>
Name and address of current
� , ..._��
. Property Description: Lot siz�
. Tax Map##:
Parcel#:
Township: � s�-� r�
'vw ✓1 9. Water supply type: �
✓I� C privat� public ❑ community ❑ spring ❑
re any wells on adjoining property?Yes ❑ Nc�
m If so, identify location:
. Directions to property: State Road #& Road
lames, etc. , � �
10. Type of structurelfacility: Proposed�lExisting: ❑ I
Type of dwelling:
House: ❑ Mobile Home: L� Business: ❑
Type of business:
Number of Employees:_T
Number of bedrooms: �
Garbage Disposal? Yes ❑ No ❑
Basement? Yes ❑ No ❑ If so, # of basement fixtures:
6 Number of occupants or people to be served: �
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 property. I understand if the site is altered or the
intended use changes, the permit 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 Dept. within 60 DAYS after the date of the evaluation of
� the site by the Health Dept., this application s��becom�void�td all fees paid forfeited.
-' ned O'v�ne or Authorized A ent
Permit Issued ❑
Permit Denied ❑
Plat Observed ❑
Signature Date
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RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
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B1059 �
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVI�'ROVEMENT PERMIT
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 # � � � Parcel # � �
Zoning Township
Owner/Contractor ���j � {� o b� n s o�-, � e� %�y ate �f - � f-�.L_
Location/Address s
S.R.# �
Subdivision Name � c Lot# �
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area 3,3 r cv�1 Size of Tank '�-�'
SFD Mobile Home Size of Pump Tank Ni�-
Business # of Bedrooms�� Nitrification Line �[7a 3'
Max Depth Trenches
Permits may be voided if site is altered
Well and Septic Layout by
Comments:
Date 5- 3-�j (, Installed by� �'�,.._ Approved by
Well Permit Paid WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab
Public Re acement Air Vent j/
Site Approved 1� Required Well Log �/
Well Head Approved Well Tag I/"
Grouting Approved
Comments:
Date
Installed by
Approved by
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 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 si�cty (60) months from date of issuance)
DATE: �" — � - -/ � IMPROVEMENT PERMIT #: .� /D S
TAX MAP #: PARCEL #: �p �
OWNER/OWNER'S REPRESENTATIVE: DG h i P I �o�/�h s'�N
LOCATION/ADDRESS:
� cl So„� -% Sn*�- 1162 -� S�� l/6 y
SUBDIVISION NAME: �-% ir � l/'1 �( 1! e+'� LOT #:
SECTION OR BLOCK:
AUTHORIZATION FOR CONSTRUCTION ISSUED BY:
AUTHORIZATION CONDITIONS
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 # /05� . 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:
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PERSON COUNTY ENVIRONMENTAL HEALTH
' v-: : WELL-: LOG . . _ , _ --.: . ,, _� _ . : . .- . -_ ... ..
• � � " . �
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Date: s`^ �i- '
Owner:
Location/Directions:
SR# �I�L '
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Subdivision N�une: __1�� (�{�� Lot # �
Drilling Contractor: e, -�4P��
. WELL CONSTRUCT'ION
Distance from Nearest Property Line lC3 r Distance from Source of
Pollution /_tJ'-�` - -
Total Dep_ h: r?v� Ft. Yield: C'o GPM Static Water Lzvel �S" Ft.
Water Bearing Zones: Depth 7`� Ft.__/�r � F� F� Ft.
Casing: Depth: From O to �oG � Ft. Diameter:_ �/r� Inches
TYPE: Steel � Galvanized Steel �-
If Steel, does owner approve: Yes No
Weight: Thickness: ./� Height Above Ground:�_ Inches
Drive Shoe: Yes ✓ No -
. ;
Were Problems Encountered in Setting the Casing? Yes No �� �
If "yes" give reason:
Grout: Type: Neat SandJCement � Coricrete �
Annular Space Width Inches
Water in Annular Space: Yes No
_ Method: P»mped .- Pr:ssure Po � ed �` .
Depth: Fr�m r� :o �6 Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes r/ No � �
4 x 4 slab Yes No
I HEREBY CERTIFY THAT THE ABOVE INFORM�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDA.NCE WITH REGULATIONS SET
FORTH BY�THE PERSON COUi�I'Y HEALTH DEPARTMENT.
Signature of Contractor Dat�