A29 1680
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, e�'"''` /'r � APPLICATION FOR SERVICES i j r4!/ ,� o
� :: Services Reques'ted. '`
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Improvements Permit. (EstablishedlRecorded Lot) _ Reinspection of Existing System (Loan Closing)
_ Impxovements Permit (Unrecorded Lot) _. Repair/Replace existing Septic System
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Improvements Permit (Mobile Home Replace) � Permit for New Well
Improvements Permit (Addition) _. Replace Existing Well
; _:. :: _
VYater Sample fo be Collecteds,, ;
Bacteria _ Chemical Petroleum _._. Pesticide
1. Permit requested by: .
7. Dimensions or Proposed Structure:
Width: ____l�_
_ Lead
�,,�" � / � • �/ Depth: ��f
�13vn� - 8. What type (if any, additions, expansions, or
�°-��' ��%�sd� replacement is anticipated to the structure or facility
�— that this sewage disposal system is intended to serve?
ome Phone #:
usiness Phone #:.,,,5�'/��
. Name and address of,cunent owner: 9. Water supply type:
����{,//� private� . public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No�.
If so, identify location:
Description: Lot size: �
. Tax Map#:
Parcel#: _
Directions to prop�rty: State Road #& Road
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10. Type of structure/facility: Proposed: �Existing: Q
Type of dwelling:
House: ❑ Mobile Home� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: � L
Garbage Disposal? Yes ❑ No 0
Basement? Yes ❑ No i� If so, # of basement fixtures:
� 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 shal�ecom�oid a�►d all fees paid forfeited.
Authorized Agent
Permit Issued ❑
Permit Denied ❑ '
Plat Observed ❑
Signature Date �`7�" ��' %�
;. ;: . .. ,.:; ..;..�ACI'ORS-STfEEVALUA770T�F <;; ;:; ' ,X1tE":�: �. .. ':; . .' AREX2 `ARFrS3 :: ARFAd
__ ._ _ _ _ _ __ _ _
L SLOPE(%) S S S S
S O�, YI�� PS PS PS
� L� U U U
2. SOQ. T'IX71JRE (12-36 IN.) S S S S
(SANDY, LOAMY. CLAYEY, N07E 2:1 CLAY) S �/ PS PS PS
�l `" U U U
3. SOIL S7RUCRlRE (12-36 IN.) S /�� yJ S S S
(MYEY SOiLS) PS ` j�/ j PS PS PS
/�'�-� U U U
3. SOIL DFP7}1(IN.) S S S S
S �/ �J PS PS PS
(� U U U
S. RESTRIC(7VE HORiZONS (IN.) S S S
(IMPERVIOUS STRATA. ROCK) PS /n 1 PS PS PS
i� �/� v u u
Q SOILDRAINAGFJGROUNDWATER S S S
(DC7�RNAL&INTFRNAL) P fl PS PS PS
u u v u
�. son, rexMenatunt s s s s
(PERCOLOATION RATE7 S ��� PS PS PS
v u u
8. AVAILABIE SPACE S S S S
S 61` PS PS PS
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9. STTECLASSIFlCATION(SEEBELOW) �
SOtL SERiES
S-SUITADLE PS-PROVISIONALLYSUTfAIILE U•UNSUITABLE
RECOMMENDATIONS/COMMENTS:
STTE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope pattems, eCC.� C:lAh1IPR0\DOCSAPPSEC.SM FINANCE.PC
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT PERl�.ii i- -
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 # � � G% Parcel #
Zoning _ Township
Owner/Contractor
Location/Address
S.R.#
Subdivision Name � C Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area �� 33 a u�cs Size of Tank � n S
SFD ' Mobile Home ✓ Size of Pump Tank N! p
Business # of Bedrooms � Nitrification Line �(� ��X 3�
Max Depth Trenches � � `'
Permits may be voided ii
Well and Septic Layout by
Comments:
Date�=�(z Installed by (/1/�Mr,r /tf�n c�PY�.--- Approved by
Well Permit Paid WELL SYSTEM SPECIFICATIONS
Individual_��Semi-Public Required Slab ���
Public Replacement Air Vent �/
Site Approved Required Well Log �
Well Head Approved � Well Tag �"
Grouting Approved
Comments:
Date
Installed by
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
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•� ' AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTJON
. _ (Void sixty (60) months from date of issuance)
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DATE: �� 5— �(� IMPROVEMENT PERNIIT #: I3 /D O
TAX MAP #: PARCEL #: lc �
OWNER/OWNER'S REPRESENTATIVE: �p � n i /C o� i n Sonl
/'li��nc' /�1� � S,Tnso �,
LOCATION/ADDRESS: �
�� �S � S/�-� .J1� z � �2�- //� y
SUBDIVISION NAME: [�7 /`
SECTION OR BLOCK:
AUTHORIZATION FOR
���
ON 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 # JD� 0. 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:
:SSE W. HILL
�. 214, P. 17
NF
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S89'25'58"E
330.00'
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330.00' TOT
N89'25'S8"W
JESSE W. HTLL
D.B. 214, P. 17
TO BE CONVEYED TO
RICHARD LEE JENSEN
& NANCY WAGNER JENSEN
31.22' NF
IF
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� PERSON COUNTY ENVIRONMENTAL HEALTH
^ , • _ , • � : ,- . . - f.
' .. •. •... - _ , : ---- --
_ WELL .LOG _ _..: ,- .. . .. - - - - ..--- . . .__ .
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Date: � � "4� '
� Owner: � .�_n h �
Location/Directions:
Subdivision Narne:
Drilling Contractor: _
�l(
SR# ��C� � �
Lot #
WELL, CONSTRUCTION
Distance from Nearest Property Line /C� `-f- Distance from Source of
Pollution /.C� U �
Total Dep.th: �5!O Ft. Yield: GPM Static Water Level a�' S� Ft.
Water Bearing Zones: Depth �G a FL F� F� Ft.
Casing: Depth: From� to o?,S' Ft. Diameter: �%y Inches
TYPE: Steel � Galvanized Steel �
If Steel, does owner approve: Yes No
Weight: Thickness: ,�� Height Above Ground: % y Inches
Drive Shoe: Yes � No �
Were Problems Encountered in Setting the Casing? Yes No_�
If "yes" give reason:
Grout: Type: Neat SandJCement �' Concrete
Annular Space Width Inches
Water in Annular Space: Yes No
_ Method: Pumped -. Pr:ssure Foured � . .
Depth: Fr�m d to � v 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
0
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE VYITH REGULATIONS SET
FORTH BY�THE PERSON C^vUi�1TY HEALTH DEPARTMENT.
�,�—�� ,��:n,��.� � -
Signature of Contractor Date
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'I'ax I`+�Iap # ' D i'atcel # �(o�
�xisting Sewage Spstem Report �or. 11�Yob�e �ome Replacement
�_ Addition Type: ��.1ilD
�equester. �/��/�S� /(� 33ome �'hone#
Business #
Location: � � /��f �
Original. Y'ermit Located: �7 Water Supply: Gf%4��
Septic Spstem I�esigned For. � Residential Business Other
# Bedrooms_� # Employees Other
System Type: 'I'ank Size: Nitrification Liner
Date Installed: �'.�� - qjo Certifiesi Operator Required:
On-site wastewates disposal spstem shows no visual signs of malfunction on
Permission is granted to: �O,�S�� >>/'� rT �.��if�
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JEnvironmental �3ealth Specialist Date: ' � " �
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