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A29 175� �`� o� P �, �6�.':�-. . �-e a3.a � APPLICATION FOR SERVICES ts Permit.(Established/Recorded Lot) Permit (Unrecorded Lot) Improvements Permit (Mobile Home Replace) Improvements Permit (Addition) � H O ' ; � Bacteria l. Permit re uested owner rospective o Address: . � C� � � a w U � a _ Chemical �._z3-�� Reinspection of Existing System (Loan Closing) Repair/Replace existing Septic System Permit for New Well _ Replace Existing Well _ Pesticide 7. Dimensions or Proposed Struc ;�? o vsd � Width: �� K�� K. Depth: ome Phone #: �` ��" � g5J usiness Phone #: Name and address of.cunent owner: �; ,n �r-� . /�i // : Lot size: U�-S g, what type (if any, additions, expansions, or replacement is anticipated to the structure or facility 9�--� that this sewage disposal system is intended to serve? ,�o � � :f� Tax Map#: /-� oc � " Parcel#: - 1'7 s �: l l I� a Township: �us4..i �G.r k Directions to property: State Road #& Road mes;�tc. S�- 1�� Number of occupants or people to be served: .3 9. Water supply type: private,� . public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes � No j�: If so, identify location: L c� T�� 10. Type of structure/facility: Proposed: �Existing: Q� Type of dwelling: House: ❑ Mobile Home: � Business: ❑ Type of business: Number of Employees: Number of bedrooms: -3 Garbage Disposal? Yes ❑ No I� Basement? Yes ❑ No�'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 PeI'50�1 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 pt. within 60 DAYS after the date of the evaluation of the site by the Health Dept., this appllea�ion shall e void and�Rll fees paid forfeited. / 1 // C z �`� Si�neQ Owner or Authorized Agent Permit Issued d_,_,/ Signature � Date • Permit Denied L�J' Plat Observed ❑ � �� `� - ��<<- � � � � �� N �— � ��`�Q�� v �� ' �'" �nC.� W S� �� Y`^P ve ��' � � �— "t .. � ;_ ; : Acroxs-s��vN.Unno� ':< :: :�sc: n�xz . ; �ns nx�+a _::,: _._ _ _ 1 SIAPE(%) � S S S PS /1 � �� PS PS PS (/ U U U 2. SOIL :'FJC'�URE (I.-361N.) S /� S S S (SANDY. LUAMY. CLAYEY. N07E 2:1 CL1]� u �-/„ V4 V U U � � l/`t 3. SOILS7RUCil1RE(i2-361N.) S S S S ccuv�r sons� u � S5 [�'E' u v u. S. SOIL DEP7}t (IN.) S � S S S p l PSj PS PS PS U P� � U U U S. RES'fRICTiVEHORIZONS(IN.) S GiJ^'� S S S (AIPERVIOUSSTRATA,ROCK) PS PS PS U� U U U 6. SOILDRAINAGFJGROUNDWATER S S S S (DCTFRNAL R iNTERNAL) U �'�'�QS U U U 7. SOII. PERMEABILTiY S S S S (PERCOIAATION RA7E) PS PS PS PS U U U U 8. AVAII.ABLE SPACE S S S S PS PS PS PS U U U U 9. STfECLASSIFICAi70N(SEEBELOW) SOILSERfES S•SUITADLE PS-PROV1S10NALLYSUITADLE U•UNSUITABLE RECOMMENDATIONS/COMMENTS: SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope patterns� etC.� C:WMIPRO�DOCSWPPSEC.SM FWANCE.PC . t-- • . V, � a w � a • PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT 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 # �� 9 Parcel # ��J` Zonin Township � r � g Owner/Contractor �r, h,�1 � P � Ti�. ate �� —� 9� Location/Address ��,�,� wra,„ %Ld � ��' S�� / /6 � ,_ _ __ S.R.# //� � Subdivision Name ��-2S'S'r e l� �'ll Lot# �� Permits may be voided if site is altere r in enc�ed u e changed. Well and Septic Layout by �i .'/� ,� ��v�� Comments: Date Installed by � � �,,i1,"�- Approved 'ell Permit Paid [� WELL SYSTEM SPECIFICATIONS dividual Semi-Public Required Slab _ �blic eplacement Air Vent te Approved Required Well Log ell Head Approved Well Tag -outing Approved �/�/�-�j� 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 H 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 � • - � AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (Void sixty (60) months from date of issuance) DATE: �-� 3-�� IlVIPROVEMENT PERMIT #: D TAX MAP #: � PARCEL #: OWNER/OWNER'S REPRESENTATIVE: �}, �►-� Se 1�� c,,J ,_J Y; LOCATION/ADDRESS: 5�2.�� i C�� C,��,,► �,�J,-�., � d2�',. s� ��d z � - _. SUBDIVISION NAME: �� S Sz' C. �� I LOT #: SECTION OR BLOCK: 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 Pernut #� �D r% . 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 pernuts. 4. Conditions: Person Requesting: JUL 31 '97 11=42 rH�t.uei � . . . , . ' /� �` � a.�C..� /`� v � � ` � �-�d -- ' � � �'o�� .� `• _ .�,p� 5�p �� r�� , �. ��- , S � -� . . R � - ��r rs J� ��•- � �F � '� 6' iiE Y1_ HILt / 34.t5'`' � � ��-�� 214Pt! / ��r� / E F ~� � Z NF � � �- / ,� � QpY1D E. EVANS '�" �'�,� �'~ � UE3 258 P 487 �'�( � �,� / :�",`,� `� ~ `'�`"� .� / • ��,o � ` �--- �, � �h . � I F 2ry�°^ � prY � . �, S` .. �5a ''� < \ � � q- _ ' �o � I 5 - ` �( � n.`� �iARYlN G. WIl50Af $6� � e��j� yn,�' 09 241 R 549 j ` 2�, \ � � { rsp Q�9r� �1`C t 1 I i �� ,s f ' � z cNo 599'25'58"E ! (��' I � +� � � • �� F. ; �4.88� I i . ,P i � L� R � J � � � � G�, e � � � _j� i3o r�F � v ` W �: � 1 � : '� ES� EASEM NT � j _ ..:._._ - -�---� l . _ _ _ ..�s �, rt�- �,o � - �k- - Ns � IS,: �IS�J ��1 C� � — – 33�.00' ~ � – —•- � j 32.00� r�–�' I� fag9'25'S8"rr NF i _ �� '�' `� . { � IS / �z.00� � � Ga �"1 . j S � r � � �� N � a Q f}ANIEL M. RQ8[NSQN � IS so.00' IS �� p9 255 P 4�49 � � �� _ � s 8 i ' i� � ._,a a' i vai ( I t73 rs "- _�- ( -a• : � � • J IF ---•--------------�-- 1 t� w d ! � I - � F � v � � 1l�/" 1 1 ! ' � � 1 ,<_� � '� � .�� o .` .. �_ E �� . - ��" ** TOTAL PAGE.001 ** � M� �►-� ��e i� L 3 � � � • • . • � . , . Date: . - /��-�' . Owner. _ �ss r,� �� Location/Directions: � Subdivision Name: Drilling Contractor: PERSON COUNTY ENVIRONMENTAL HEALTH WELL LOG ' s 2s5 �r� S � n SR# LOt # i . WELL CONSTRUCI�ICYN -- Distance from Nearest Properry Line /O Distance from Source of Pollution /�� ` Total Dep.th:. �dn Ft. Yield:_� GPM Static Water Level 02 S� _Ft. Water Bearing Zones: Depth ,�G / Ft. ao F� Ft� Ft. Casing: Depth: From_�_to�_Ft. Diameter:�, 7nches TYPE: Steel � Galvanized Steel � If Steel, does owner approve: Yes No � Weighc: Thickness: /X� Height�Above Ground: /�/ Inches Drive Shoe: Yes � No Were Problems Encountered in Setting the Casing? Yes No ._ If "yes" give reason: Grout: Type: Neat Sand/Cemen[ .� Concrete Annular. Space Width Inches Water in Annular Space: Yes No. _ . Method: Pumped . ._ . �Pr�sure � . � Poured ..� � - � . . ,, _ : - Depth: From C� to � a Ft. - � Materials Used: No. Bags Portland Cement Weigh[ of .1 bag__lbs. If mixture (sand, graveI; cuttings) - Ratio: to �ID Plates: Yes �/ No � � �� 4 x 4 slab Yes ✓ No I HEREBY CERTIFY THAT THE ABOVE INFORM�1'IZON IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH �y�THE PERSO�I C�Ui1'I'Y HEALTH DEPARTMENT. � ��.�� _. �Signaturc of Contractor Dat� ►.. i �