A29 172A•mount paid ��0�00 '7-�Q-°� �
Receipt �l � � �`18� Date
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Bacteria Chemical Petroleum Pesticide
1, permit requested by: .
�wner/orospective owner/agent: �� � A 1�- r �e� _
Address: �� 3�3 ��. ues a
+� A.vl,-c�� �UG o�'�5'�' 3
ome Phone #: 33�• 59'� � 9� `� 9
usiness Phone #: g1 �J� l�l � � %a(a�
I�Iame and address of current owner.
7. Dimensions or Proposed Structure:
Width: a �' � �' —
8. What type (if any, additions, expansions, or
replacement is anticipated to tk►e structure or facility
that this sewage disposal system is intended to serve?
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9. Water supply ty pe: --
private�. public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes �. No [�.
If so, identify location: ���o�s P � r��"��
. Property Description: Lot size: l.o Hc
. Tax Map#: /� ��.9 I0. Type of structurelfacility: Proposed: �Existing: Q
Parcel#: ��'a � Type of dwelling:
Township: b I i�e u�! House: �-Mobile Home: Q Business: f�
'�pe of business: ,
�. Directions to property: State Road #& Road Number of Employees:_______
�aS �'9g� �b �1es�e�e Sfv2� ,�(, -1 �,��(� Number of bedrooms: _� �Z
e � �-�� � ]�,;� . ���P�fsoh �-d � � °�'� _�{'�' _ Garbage Disposal? Yes ❑ No�
, ,, T Basement? Yes❑ I�Io�I If so, # of basement fixtures:
Number of occupants or
to bC seNCd: �_
1
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AI�ID THE CORI�IERS OF ALL
PROPOSED STRUC�'URES•
I hereby make application to the Petsolt COunty T3ealth Depal'tment for a site evaluation for the on-sitc
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 �
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have no�
delivered a survey plat of the property lo the Health Dept. within 60 DAYS after the date of lhe evaluation of
tha site by the Health Dept., this application shall become void and all fees paid forfeited.
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B 2394
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT
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 - ` ; l
Owner/Contractor � .t b C( � C . � � -�- � Z.�-�' Date -7 - 1 b- � �
Lo�ation/Address �-i R S 7"� � l�l � S�-r-,�-S ��z�� _ � ��27`�,� _
�lnl — Is�(�,�S.R.#
bdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area 1• C� �-C.._ Size of Tank ���0.Q.
SFD �- Mobile Home Size of Pump Tank i�' %!_�
Business # of Bedrooms 3 Nitrification Line I--(� ��'
Max Depth Trenches o? � �'
Permits may be voided if ' e�s a ered or i tended u
Well and Septic out by 0
Comments: �`� ,("� ,Plln
Date Installed by 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
Approved by
-?(r614�c�ac
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 misleadi�g statements provided to
him in the application. Neither Person County nor the eovironmental 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:\amiprolpermit.sam O1/95 rev.l.l
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