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APPLICATION FQR SERV�CFS
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3! Permit requeste
owner/prospective
Address:.f .-7 s �
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� usiness Phone #:S�'7–S��/�/
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Property Description:
Tax Map#:
Parcel#:
TownshiD'�
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Petroleum _ Pesticide _. I.,ead
7. Dimensions�or Proposed Structure:
� ,�S � �� Width: �� g -
�a . Depth: � � _
8. What type (if any, additions, expansions, or I
replacement is anticipated to the structure or facility
[ha� this sewage disposal system is intended to serve?
er: 9. Water, sup 1}'pe:
� private public ❑ community ❑ spring ❑
�� �� a- Are any wells on adjoining property?Yes`.� No�.
, �' , _ If so, identify location:
. Directions to property: State Road #& Road
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�pe of structure/facility: Proposed: QExisting: Q
Type of dwelli :
House: Mobile Home: [� Business: ❑
Type of business: � ^ ► *�`
Number of Employees: —
Number of bedrooms: �_
Garbage Disposal? Yes ❑ No I�
Basement? Yes ❑ No�31f so, # of basement fixtures:
6. Numbei of occupants or people to be served: t_
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES. �
I hereby make application to the Pet'SOII COIInty Health Departmen n�ents of th s aupli�ation ahe true ite
sewage disposal system for the above described property. I agree that the co P
and represent the maximum facilities to be placed on the property. I understand if the site is altered or the
intended use changes, the pecmit 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 [hat in the event I have not
delivered a survey plat of the propert the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this a li�tion sh�il become void�and all fees paid forfeited.
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Signce� Owner or Authorized Agent
Permit Issued ❑ Signature
Permit Denied ❑
Plat Observed ❑
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Date
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RECOMMENDATI ONS/COMMENTS :
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, properiy lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.� C:UMIPRO\DOCSU�PPSEC.S�1 FINANCE.PC
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B 1417
PERSON COUNTY HEALTH DEPARTMEN'�'
- WELL AND SEWAGE SITE, LOCATION IlVIl'ROVEMENT 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 # � q
Owner/Contractor
Location/Address
ON
Subdivision Name
Parcel # / �
Township �
S'n-, , =�1,
D vt
LOt#
Date �/- �
rY�1Pv S.R.# 11 _�
Permits may be voided if site is altered or
Well and Septic Layout by �
Comments:
Date
ell Permit Paid
Head
Comments:
Installed by
Approved
�r �c , �-
SYSTEM SPECIFICATIONS
Semi-Public Required Slab
Zeplac ment Air Vent
Required Well Log
Well Tag t /
Date % .�- 9 � Installed by
Approved
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 ia 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 CONSTRUCTION
� ' (Void sixty (60) months from date of issuance)
DATE: -3 — l� IMPROVEMENT PERNIIT #: %
TAX MAP #: PARCEL #:
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OWNER/OWNER'S REPRESENTATIVE: � //`'�
LOCATION/ADDRESS:
� I � v t'''l � I o � G �'1 �j t�✓!P fi p� • �� / �,.5% � ��d Z
SUBDIVISION NAME:
SECTION OR BLOCK:
LOT #:
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 #�/���. 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:
' " Date:1-�q 7 .
Owner: ��,�
Location/Directions
�e'� M257`e� cSeccr
Subdivision �Name:
Drilling Contractor:
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
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Lot #
Distance from Nearest Property Line /v Distance from Source of
Pollution �ao '
Total:Dep.th:� /ho Ft. Yield: c5'o GPM Static Water Level as— Ft.
Water Bearing Zones: Depth �_Ft. F� � F� �t.
Casing: Depth: From �� to ac� Ft. Diameter. l/� Inches
TYPE: Steel - Galvanized Steel �—
If Steel, does owner approve: Y�s No
� Weight: � Thickness: /8� Height� Above Ground:� Inches
Drive Shoe: Yes � No
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" give r�ason:
Grout: Type: Neat Sand/Cement � Coricrete
Annular Space Width Inches
Water in Aruiular Space: Yes No
_ .. Method: Pum�a . - Pr�ssur� � � Po�r�a .� . _ � - -
Depth: From b to ao Ft.
Materials Used: No. Bags Portland Cement Weight of .1 ba�_lbs.
If mixture (sand, gravel; cuttings) - Ratio: � to
ID Plates: Yes � No � �
� 4 x 4 slab Yes ✓ No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTTH REGULATIONS SET
FORTH BY�THE PERSON Cvui�ITY HEALTH DEPARTME
Signature of Contractor Datc
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158.30' NO2'34 19 E� 4:
- - �, 109.53! 109.10' �
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PROPOSED o ADDITIONAL o 30' R/W �
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