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` 5er�ices Requested
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Imorovements Permit.(Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing)
ments Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
Bacteria
1. Permit requested by: .
owner/prospective owner
Ar�r�rPcc• . � �,.�/V..
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ome Phone #:�C�� - 793— ��3 �
usiness Phone #:�'�� �"Z-9�0Z�
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. Name and address
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Repair/Replace existing Septic System
Permit for New Well
_ Replace Existing Well
Petroleum
_ Pesticide I ,_ Lead
7. Dimensions or Proposed Structure:
Width: l�o � s�_��"
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 su,pply t}•pe:
private �public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No [J
–�So If so, identify location:
. Property Description: Lot size: 1, 1 o ti�
. Tax Map#: �4 � �1 �,l�i%r9l��N
Parcel#: y � Z �'� �
Township: --Q �
. Directions to property: State Road #& Road
ames,�tc.
Number of occupants or
�- ��1� 2-
to be served:
10. Type of structure/facility: Proposed: DExisting: Q I
Type of dwelling:
House: ❑ Mobile Home: L� Business: ❑
Type of business:
Number of Employees:-�-
Number of bedrooms: �`�.
Garbage Disposal? Yes ❑ No �
Basement? Yes ❑ Nofl 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 PerSOI1 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 ihe Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
��
z �Signc� Owner or Authorized Agent
permit Issued ❑
Permit Denied ❑
Plat Observed ❑
Signature Date
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RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, s[reams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.)
C:MMIPRO�DOCS�APPSEC.SM F1NnNCE.F'C
_ A TERSON COUNTY HEALTH DEPARTMENT
� r • � WELL AND SEWAGE SITE, LOCATION IlVIl'ROVEMENT PERNIIT
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B 1202
Not for w�ste water system construction. No permit(s) for Construction Location or
Relocat`on Activity shall be issued until Authorization for waste water system construction
has b�en issued.
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Tax Map # ,�� Parcel #
Zoning Township O�j` V P f.� ��l
Owner/Contractoi•��y��T,�� S Date_=�'r�—,,��—�7�7�_
Location/Address UG <�. t�.;,- i��,� I„!� .n� �c� �'
Subdivision Name
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SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area �, /� ti. � ��J
SFD Mobile Home �/
Business # of Bedrooms_�_
Permits may be voided if site is altered or
Well and Septic Layout by
Comments:
Date
Size of Tank_�
Size of Pump Tank
Nitrification Line
Max Depth Trenches
use
:npprovea by
Well Permit Paid ELL SYST � SPECIFICATIONS
Individual Semi-Public Required Slab ✓l��� ��
Public Repla ent Air Vent
Site Approved Required Well Log �(/,�1, d,)
Well Head Approved Well Tag �/ (l.v, D,) �
IGrouting Approved , Q.
Comments:
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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 resp�nsible for false or rnisleading 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 Cou�ty 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
- AUTI�30RIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
' (Void sixty (60) months from date of issuance)
DATE: y IMPROVEMENT PERMIT #: C� /2 O Z
TAX MAP #: PARCEL #:
OWNER/OWNER'S REPRESENTATIVE: Q 1/t � �V�t n-S
LOCATION/ADDRESS:
( x ipl�r�� on �re�h �s�i
SUBDIVISION NAIv�:
SECTION OR BLOCK:
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4
s� LOT #: � 4
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AUTHORIZATION FOR CONSTRUCTION ISSUED BY:
AUTHORIZATION CONDITIONS
1. T'he Wastewater system constn:�t:on znd iastaltation must meet all of the conditior�s of tfie
attached site plan and specifications as set forth in Improvements Permit #��'�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:
— — --- _
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�S . , . S62'45'45"E �S S64'17'04"E
S61 25 49 E 74.46'
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158.84' Nc� 64.93 •
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l'L•'1tSUN CUUN'I'Y liNV11lUNMliN'I'AI. IIL:A�.'1'��
C�� �� � WELL LUG
Date: -� '`�o
Owner: � � �
Location/Directions:
Subdivision Namc: ,
D 'llin Contractor•
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SR#
Lot #�
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WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollution _
Total.Dep.th: Ft. Yield: GPM Static Water Level Ft.
Water Bearing Zones: Depth Ft. __ Ft. Ft� Ft.
•� L h
Casing:
TYPE:
Grout:
Depth: F�om,_.,Q_���--Ft• Dlameter. �_ nG es
Steel � Galvanized Steel �
If Steel, does owner approve: Yes_No
Weighe: Thickness: .�.� Height Above Ground: Inches
Drive Shoe: Yes No_—_____ `;
Were Problems Encountered in Setting the Casing? Yes______ No
I� "ycs" givc ;cason:
Type: Neat Sand/Cement Concrete
Annular Space Width �2. Inches
Water in Annular Space: Yes _ No______
Iviethod: Pumped_ Pressure — �'o�� � --
Depth: From � to � Ft• �
Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs.
If mixture (sand, gravel, cuttings) - Ratio: �o
ID Plates: Yes�_ No �
4 x 4 slab Yes No______
I HEREBY CERTIFY THAT THE ABOVE INFORMr�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON COUNTY HEALTH DEPARTMENT. �
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Signature of Concrac _ . Datc
PERSON COUNTY HEALTH DEPARTMENT
SUBSURFACE WASTEWATER SYSTEM MONITORING REPORT
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Date of spection System Installation Date Type Tax Map Parcel #
/Z�°I ff�S�P►-s Saa� l�c�
Property Address
Instructions: Check yes or no for appropriate items and explain in space provided for re�arks and
comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate
by "N" and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance
and monitoring items specified in the permit are to be carried out.
INSPECTION RESULTS
COLLECTION SYSTEM:
Evidence of leaks ?
Tank risers accessible, free of
infiltration and surface water diverted ?
Septic tank needs pumping ?
Inches of solids:
Septic tank filter cleaned ?
YES / NO
❑ / ❑
❑ � ❑ �
❑ � ❑
EFFLUENT DOSING SYSTEM:
Required pumps present & functional7
High water alann operating properly ?
Floats, valves, etc. in good condition ?
Control panel & components in good
condition ?
Effluent free of excess solids ?
Inches of solids(pump/dose tank):��
Elapsed time readings ?
Counter readings ?
Drawdown rate: /,[_
p i pN
❑ � ❑/�
❑ � ❑/V
DISPOSAL FIELD:
Evidence of effluent surfacing ? ❑
Evidence of effluent ponding in trenches ?❑
Surface water effectively diverted ? �
Diversions/swales properly maintained ?
Vegetative cover maintained ? �
Protected from traffic/unauthorized uses ? �
Distribution devices in good condition ?
Field free of settled or low areas ? �
/
/
/
/
/
/
/
/
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PRESSURE DISTRIBUTION SYSTEM:
Turnups/cleanouts/valves/taps intact &
accessible ? ❑ � ❑ N�
Pressure head properly adjusted ? ❑ / ❑ /�(�-
COMPLIANCE:
Compliant
Non-compliant
Needs Maintenance
ADDITIONAL COMMENTS:
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REMARKS
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