A29 28Ap�afication Daie: 7'��'0�
Amount Paid: I���
R�c�i t �: ,�741 7
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APPtJCAT10N FOR SERVIC�S
'iax lAao #: � G �
Pareei �: �. � �i`6
IF THE� IPIFORMATION 1N THE APPLICATION FOR AN tMPROVEMENT PERMiT IS INCORRECT FALSIFiED
CHANGED OR THE SITE IS ALTERED THEIV THE IAAPROVEMEA{T PERMIT APID AUTHORIZ�►�ION TO
C�NSTRUCT SHAL� BECOME {MVALID. . � '
1) Permit requesteii by: (Owner/agerrt/�rospective owner): 1� L w+
Hame Phone: ��5 7- al � S� � Address: � 2- e e ��s S,
Business Phone: S5 S- 7��, . . ti- �.
2) iName and address of.current awner.
3) Property Descriptian: Lot size: ' 1�` „P Township: L � 1 1 Subdivision: 1: e�, �,� �2 ��rQ L Lot #�
Directions to the property (Including road names and numbers): ��i S R� �� 1�� <,� �r �s 5�a �o
4) Proposed Use and Structure Description: answer each of the following questions: .
a) Proposed . Existing ,�, Type of Struciure: I-�o � s � Width: � Depth�
b) Number of Bedroom5: �_ Number of occupants or people�to be served: _L .
c) Basement: Yes , No � Will there be plumbing in the basement?
d) Garbage Disposal: Yes � No �, .
5) �Uater Supply Type: Private _(new _ or existing�, Public . Community�, Spring
. � Are any welis on adjoining propert�? Yes� No _ If yes, please indicate a�proximate location on the
� site plan. � .,
6) Does your pro�erty contain previousty identifiecd jurisdictional wetlands? Yes_ [do�
PLEASE NOTE THE FOLLOWiNG:
➢ A PLAT OF THE PRt7PERT1( OR 5Il'� PLAN MUST BE SUBMITTED WiTai THIS APPl.ICATION.
➢� PROPERTY L1NES AND CORNERS NIUST BE CLEARLY MARKED.
➢'Y'HE PROPOSED LOCATION OF ALL S7RUCTUFtES MUST BE_ STl�l�D OR FLAGGED,
➢ TFiE StTE MUST BE READILY ACCESSIBLE FOR AN E1/ALl1AT10N BY THE HEALTH DEPARTMENT
STAFF.
I herehy make applicatio� to the Person County Health Department for a site evaluation for the on-site sewage disposal
system for.the above-described property. 1 agree that the contents�of this application are true and represent the rnaximum
faciiities to be placad on the property. i understand ifi the site is altered or the intendecl use changes, t(ie permit shail
become invalid. � /%
Owner or Legal Representative
7/�v �
Date
PCNO, rev. O6I27IO2
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� Autho�ized State Ageut - . Date � . �
syate�m c,ompone�s r�br�s�i"rr�a�axsaara�e��urs osad�►. The �r muss,�lag td,e s,�►stem prd�-t��
,� '�egrisstiasg #lia �ststaAa�oss #o snsuns tdaat�iro�se�'g�'ade ss m�ned .
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P�,=ev 09/�2/01
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T� �a� #: Aa� �az�. # �_ ��P .
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Snbdivasion:
On �
Se�t'son:
l S �, ��-�S-E�.s �forc. %Zoc
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��111TCffiCYl$S:
Site Approved bp ��-Sg �� a`-!- b3
Gmuting ved. by✓ -7 -� N� �3
Well Log ��H 1 a�-c73 .
�Tell T�, ✓c�55 ��a�-1��3
Air Vent �
Hose Bib
Concrete Sla
��te �P o,�-� ��5,� .1 ��
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Well.A�roved �3y: I��ge•
'�°5ee Axtaci�esi Sat� Sketc3a'�
Wells must be 14 £e�t from properl.y lines.
Wells must be 100 feet from septic spstems. �
Wells must be ax lea.st 25 feet from anp bu�d'mg foundaxion.
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�ca �S�c�n .
PCF�, rev. 09/07/01
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�;�'t��.e�Log �
Owner: //�1�� : 5� ��v�v� _ T� Map � Parcel # �_
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�'Vell Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from Septic System (Minimum 60 feet}
Total Depth: i20 ft Yield: GPM Staric Water Level: _�� ft
Water Bearing Zones: Depth -� ft ft ft
Casi.ng: ,
Depth: Fram �_ to �j� ft_ Diameter: �� /�
Type: Galvanized Steel �_
Weight: Thiclmess_ �� Height above Ground: ��_ in
Drive Shae: Yes No Any problems encountered while setting casing? Yes _�o
If "yes" give reason: ,
Groat:
Neat: Sand/C�ment
A.n.nular Space Width
Method of Grout: Pumped _
�/ Concrete GraveUCement
_ inches Water in Annular pace Yes
Pressure Poured Depth to
IViateri�is Used:
No. Bags Portland cement y ��Weight of 1 Bag �_ Pounds
If mixture (san� gravel, cuttings) — Ratio to
ID plates: t/ Yes _ No 4 x 4 slab es _ No
No
Iiriltinu i.og Location Dra�s�ang
lFroffi i'a �'ormation
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I hereby ceztify that the above info ati�n is eorrect and that ttus well was construct�ci in accordance with regulations
set forth by the Person County H Department.
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