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A29 17A:�unt paia Id.� �� �-3-9�' " Receipt !I �_ (1z°( Date • C'�- I � '�� �1PPLICA'�ION TOT2 SERVIC�S � 3� y Y'. +�.,,. %' i r a a" e: 7+,. �.,�e'•7f. E`sx�. b-�i��' :rrt�d"rw�:i: "'a`...�r.?'..il�.' `'s �c.•R,. tif4�t'��(yP -�i� S, t'",� "�'i7.+,�'_3 .j�'x��'i�. } T 1.� p°Ft�l � h�`�� R�,f'H�-.�-a;�. '� . ,r..e ��°kx�"i x a�C- ?��" �C: a`�:^G,Yrr` '�.U� �'��.'ca ��'ri�' �y� x Z��.' I_ .�.�-.✓<«�,y..a� v ii„zr� � 43�` .3 �:w r e s- ,>x � �. et� y'�,���, �t.�` � �Ser-vlc�"e..s`'�Reques�'ed � �T�.�a�.ktx,,�tiT.;y;...n;s�.,9<s:: x.�,. _., t�...,�i.�.�S�.,,.��.� � 'v:� u`'�t.:N , r Es'':;x <s. �.. o��+ r,x � �t-iDF= a�'`��;.'�`.`,�::. _ :t*c.�,v� . ��,+a ,.� .,«.>:; ^ ,+.: Improvements Permit.(Established/Recorded Lot) _. Reinspection of Existing System (Loan Closing) Improvements Permit (Unrecorded Lot) _ Repair/Repiace existing Septic Syslem � H O � � w U � a Improvements Permit (Mobile Home Replace) ._ Permit for New Well _ Improvements Permit (Addition) _ Replace Existing Well � C�.�•� nit requested by: ./ �1nv� w���h prospective owner/agent:� � �' ;s: !aa _. �-la-ss�l� �-lo -���. ? cl I� �m � l Irs Y� �. a� su 1 _.__ _. ��- � ome Phone #�9�v.� usiness Phon #: ` Name and addre�s of,current owner: 5 a-�Q . . Property De� . Tax Map#:_ Parcel#: _ Township:_ . L.ot size: Directions to property: State Road # ames,�tc. : `� � So ��n� �� l,J }t Gt v� /jc 7. Dimensions or Proposed Structure: Width: � � 6— Depth: a-� 8. What rype (if�any, additions, expansions, or replacement is anticipated to the s[ructure or facility . that this sewage disposal system is intended to serve? Number of occupants or people to be served: a 9. Water su ly type: ' private public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes C'�No [�,. If so, identi� location: �� � h u�`� �''F d� l—f'�-� � 0. Type of structurelfaciliry: Proposed: [�'�xistirig: Q I'ype of dwelling: ,,�� House:0 Mobile Home: L��3usiness: ❑ Type of businesr. " Number of Employees: _ _ ::. Number of bedrooms: �— � Garbage Disposal? Yes (� -�� Basement? Yes❑ No If so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF. ALL PROPOSED S1'RUCTURES. - _- I hereby make application to the PerS0I1_COunLy Health Department for a site evaluation foc the:on-sit� 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 unders[and tfiat before an Improvements Pemiiti can 1 issued, I must present a survey plat of the properiy to the Healtti Dep� I understand thac in the event I have nc�+ delivered a survey plat of the property to.the:Health;Dept. within 60. DAYS after the date of the evaluation oi the site by the Health Dept., this application shall become void and all:fees paid forfeited. � ,: � . �- � w�--�__ z Si nc� Owner or Authorized Agent g. ?ecmi[ Issued ❑ Permit Denied ❑ Plat bbsei�ved❑ Signature 4 �,� Date � " � ...:: : . :.. . .. .. �> . . . ;:� - .. _ . . . . :.� . . . . . �� . . . � ' ... . i - . . . _ . . . - . . � . ' . . •_.y --- -..,._.... : . < ., . _ . •:,::_-.,:. _ ..._..._ .. . ..... . _.....✓_._....�.._.._�.... .. .... _ .. . . -,•n: ._ ..y.,.,.::�" ._. . .. vi M�:��' .GTOR.� /u.t11t +s.rr3;�..;t��X4�"'�'. w� "`'3� v�` ,3�w � w..��� �.3''�c���� .�u ��"'�..... ,z.'�, } � , � .s��:a.�.>'�C'.`.�Y'�'�.C:..... 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X \ . /. � I � � � � � � � � a W U ¢ a B 2193 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Not for waste water system construction. No permit(s) for Construction Location or Relocation Activity shali be issued until Authorization for waste water system construction has been issued. Tax Map # � �� Parcel # � � Zoning Township � 111 Owner/Contractor �' !`e �' n - Date � 1/- Location/Address � �' � �, � �°�5-1-�? t'S 5-h� r-e_. � L l� � c�r� - � i-,�� �t � S.R.# Subdivision Name Lot# SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area � 3. q oZ Size of Tank %��OxCL( . SFD V- � Mobile Home r� Size of Pump Tank Business # of Bedrooms�_ Nitrification Line `��5 � X�3 � Max Depth Trenches o�D" Permits may be voided if site Well and Septic Layout by Comments: red or intenc�c�.,use changed. Date_ii�_ Installed b Approved bY Well Permit Paid ❑ WELL SYSTEM SPECIFICATIONS Individual �/ Semi-Public Public Re ment Site Approved Well Head Approved Grouting Approved Comments: Date Installed by_ Required Slab Air Vent Rea ,i�i red'Well 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 speciatist warrants that the septic tank system wiil continue to function satisfactorily in the future or that the water supply will remain potable. c:\amipro\permit.sam O1/9S rev.l.l ►� i ����'� • , • ,�� . . � , f /P _ �� N �T��3 �6•W �3�1.48 n - . �� � ��_ � � ' NR � "�`T, NRI a4fE� � M Q % e 63 � 49 �/ B' w i�9. 9/'� H�sEs Tr o p X� �T ,+�8 �.0 /3. 9 �' 2 ti 1��°F� S' ' �� �—"� �— l � s �s•��. ��,w �s�. Q ����., ,�2 '� �r es ��� �� � ' ��� O �ARN '�ani 7}ot�J ��� � �� O • �-s►o '�`") �t � S �3•�*� �/• � NRB � �` � �' p�. �t' S , cp� i �yq �/3, 16a� �e'M• � v� i' �,�° 6J � 1 E� �� T / Jr q � ' s� �\\�� ,�l( s /J'q�, 4Lf/NTfN A� � � ;/ `,�• 1� � � o, • J � � � ` 2? •� .•\ �CE N � . ; � � � � / � . � C.�/�,� e�� � � a'� ,' � ' ?9' • \ �„ '' � r� , ��� � \ � j ' : � ,` . �6�0� �o� d� �- 3 - 4 $ ��P _ , ' ��--� ; � ,�--�,. /� � ��/Zc...7� 1 t 1�-1 I-`,� s . i°s s� Q� '� o!�O ��; �� nr,Ec o `• � v�1Xx• �� / / / I \ PO. `.. � .' 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