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Permit.(EstablishedlRecorded Lot) Reinspection of Existing System (Loan Closing)
Permit (Unrecorded Lot)
Permit (Mobile Home R�
existing Septic System
) I_ Permit for New Well
Improvements Permi[ (Addition) I Replace Existing Well
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Eacteria Chemical Petroleum _. Pesticide _ Lead
1. Permit requested by: . 7. Dimensions or Proposed Structure:
�wner/prospective owner/agent: ��55� l�- i,� Width: _
¢
z
8. What type (if any, additions, expansions, or
ceplacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
ne Phone #:
iness Phone #: � %� %�v
Name and addre�s of,current owner: 9. Water supply type:
'_ private �( . public ❑ community ❑ spring ❑
- ' - Are any wells on adjoining property?Yes ❑ No �.
� , °I If so, identify location:
Description: Lot size:
• A rY
Tax Map#:�
Parcel#: •
Township: �
;Il
. Directions to property: State Road #& Road
ames;�tc.
Number of
or people to be served:
10. Type of structurelfacility: Proposed: ��isting: Q I
Type of dwelli
House: Mobile Home: L Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: _3
Garbage Disposal? Yes ❑ No �
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 PexSOn County Health Depal'tment for a site evaluation for the on-site
sewage disposal system for the above described property. I agcee 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 proper[y to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the 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.
��gncu vwncr �i r�u�uvi���u r.�����
Permit Issued ❑
Permit Denied ❑
Plat Observed ❑
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Signature Date . :;— ,
SOII.'IFXTIJRE (12•361N.)
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SO[L SiRIJCI'URE (12•361N.1
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, RESiRlCi1VENORIZANS(IN.)
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6. AVAII.AB[ESPACE
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SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, iill
areas, wells, water bodies, slope patterns, etc.) C:WM[PRO�DOCSU�PPSEC.STIFWANCEPC
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B 2377
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMl'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 6een issued.
Tax Map # � 2 Q Parcel # ���
Zoning Township �� i v�. �--1� �)
Owner/Contractor � � ;-}-1.-, Date -Z�-
Location/Address 5T �-�-e.f' S� T' L W e p-
� e� � tst �,�L (� e S.R.# 1 I by
Subdivision Name �c� 5S ,� I-� : I( Lot# /--�
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area�� Size of Tank / D�f� qOc�
SFD - Mobile Home Size of Pump Tank
Business # of Bedrooms_� Nitrification Line �� �� X3 '
Max Depth Trenches � �{ i�
Permits may be voided if site is
Well and Septi ayout by
Comments: �� ,L���-
Date �
ell Permit Paid
Individual��Semi-Public.
Public �lacement
Site Approved
Well Head Approved
Grouting Approved
Comments:
Date
Installed by
or intended
� ' Approved by.
�f2�° � �26 -q �
SYSTEM SPECIFICATIONS
Required Slab j/ a vl �
Air Vent
Required Well Log
Well Tag � /
/� i ►. i �-
Approved
This report is based in part on information provided the homeowner or his/her
representative i� 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
specialist warrants that the septic tank system will conti�ue 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 CONSTRUCTIOI�I
(Void sixty (60) months from date of issuance)
DATE: J� - Z2� 9�
TAX IviAP #: 2 Q :
II��PROVEMENT PERMIT #: Z3 -T�1
PARCEL #: ��_
OWNER/OWNER'S REPRESENTATNE: T'� � �rn ���--
LOCATION/ADDRESS:
SUBDIVISION I�IAME:
SECTION OR BLOCK:
AUTHORIZATION
ISSUED BY:
AUTHORIZATION CONDITIONS
LOT #: - —1
1. The Wastewater system construction and instal[ation must meet aIl of th conditio s of the
attached site plan and specifications as set forth in Improvements Pernut #�The
constn.iction and installation must also meet aII appiicable niies and laws.
2. No portion of the Wastewater system shall be covere,d or placed into use until inspected and
approved by the Person County Health Department.
3. Any atterations in site or soil conditions (including structure tocations) or modification in use,
design wastewater flow, or wastewatec characteristics as specifred in the associated improvement
permit and application, may void this authorization and associated pecmits.
4. Conditions:
.
1''� 50'
Lo�-y �ess�e +-<<��
T; m � r� :��,�,
I�
32g.54' TOTAL
is sss�29 � 07��w
194, 16 �
N82'45' 16''Vy
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Date:,_/� -oZ q -4'Sr '
Owner: �'� .,�
Location/Directions:
Subdivision N`ime:
Drilling Contractor: _
_. , .. . _ __.. . ._ .. ._. ,._ _... _. •
PERSOH COUNTY ENVIRONMEHTAL HEALTH r Fx .
. ,.� .— � /1�,u��: �:
� hl
WELL LOG • • � �'
; .
� � #� �
�iQc �'O_ ./ J .., .�� " .
�-
Lot # --
WELL CONSTRUCTION �
Distance from Nearest Properry Line �p Distance #�rom Source of
Pollution_ �l� '
Total Dep.th: t�o _ Ft. Yield:� �'U___ GPM Static Water Level ,7�_Ft.
Water Bearing Zones: Depth 4��s Ft. `/�f' F�. F� �t
Casing: Depth: From 6 to�_Ft. Dia�rneter:_�' � Inches
TYPE: Steel � Galvani2ed Steel �
If Steel, does owner app:ove: Yes No
� Weighe: � Thickness: t YS— Height Above Ground: /�_ rnches
I?rive Shoe: Yes i No
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" give r�ason: —
Grout: Type: Neat Sand/Cement �' Concrete
A.nnular. Space Width Inches
Water in Annular Space: Yes No
_ .. Method: Pumped . .- Pr�ssure � Poured ` .._ . . . ,
Depth: From O to a o Ft. . .
Ma[erials Used: No. Bags Portland Cement Weight of .1 bag__lbs.
If mixtuie (sand, gravel; cuttings) - Ratio: �o
�ID Plates: Yes �' No � � :. �
� 4 x 4 slab Yes r- No �
Z HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH REGULATIONS SET
FORTH By�THE PERSO�I C�ui�ITY HEALTH DEPARTMENT.
��y-�_
ignature of Concractor Datc