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' l� � � G� � APPT,ICATION FOR SERYICE.S r' ' '
__..._...:..:..,<�: � :..�::�....,.;�.��.�� _ �. _�.
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Improvements Permit.(EstablishedlRecorded Lot)
Impzovemen[s Permit (Unrecorded Lot)�-
____ ilnprovements Permit (Mobile Home Replace)
Improvements Permit (Addition)
Reinsaection of Existing System (Loan Closing)
RepaidReplace existing Septic System
� Permit for New Well
,—
_ Replace Existing Well
;ir�e
�Permit requested by: . �
wner/prospective owner/agent
�ddres ' � a v �- ��
x�-c� ►� �--
ome Phone #. 10 . ��U
usiness Phone #: «�-
>.. Name and add ess of rrent ovr�ner:
��+J��. � . �f� �J
� �D
�� ,� ��o ,J L �?S7 3
3. Property Description: Lot size�
Tax Map#:
Parcel#: _
Township:
�
�i'0 t�JtJ i �
7. Di nsionspr Proposed Structure:
idth: _ �o -
� Depth: -? �'"
3 8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
� ��
— �a {��
— ��r�
_ o �--
�
a, 5. Directions to property: St�te �oaci #& Roa�� ;�
¢ a n,� � (�i `�.\ �^'°� �
� ames,�tc. t'� �,
. g�1 •_� _ -i- . �
� _ �c1, o a� GL' . , 5z- �. �
E-' _ _ � . � . C,er�.,r.,. n 1,:
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9. W t�er, supply t}'pe:
private� . public ❑ community ❑ spring ❑ �
Are any welts on adjoining proper[y?Yes`L� No
,If so, identify location:
�pe of structure/facility: Proposed: �Existing: Q
Type of welling:
House: Mobile Home: C� Business: ❑
Type of business:
Number of Employees: •
Number of bedrooms: �
Garbage Disposal? � es ❑ No �
Basement? Yes ❑ N� If so, # of basement fixtures:
6 I�Iumber of occupants or people to be served' � � �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AI�ID THE CORNERS OF ALL
� PROPOSED STRUCTURFS.
I hereby make application to the PersOn COunty Health Department for a site evaluation foc 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 b�
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 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.
t l,��r� _
� ��
Signc� Owner or Authorized Agent
Permi� Issued ❑
Permit Denied ❑
plat Observed ❑
, � .
Signature
. ..� .
Date
. , • ,R �
--=� .
.� .
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fi11
areas, wells, water bodies, slope patterns� C�C.� C:1N�IIPRO�OOCSV�PPSEC.S�IFW�NC£.PC
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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 # Q 2 q Parcel # 3,A
Zoning Township L �,�,5 oC'
Owner/Contractor ' Date 1 O- I 3- �'`j
Location/Address f-lW `r ' G Ct-
/� ,-r� �12 t�,r,', n� k�'Ca�r,r, tS�3__i �-l"l i�1��-1-��,S.R.# tilwy �{Q SCNC.)
Subdivision Name
Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area j, , Q r] /� L
SFD a/ � Mobile Home
# of Bedrooms�_
Size of Tank � 0 b0 ��lZ..
Size of Pump Tank N � n�
Nitrification Line 3�p' x� 1
Max Depth Trenches o2'-1 � �
� �GN �lo �� G ste� own.s j
Permits may be voided if site is altered or intended use ch
Well and Septic Layout by Sp �� 5=��e C('; N�1 sa�
Comments: ���.�wa�t' Q� �r1 .
❑�
Dat�e 11-- S-` Installed by����1,, r�� __ Approved b�,��;�,,�1 �/Ca.��Y
Comments:
47
�...� ..,t,.,_. _.. ...»„�» --- r---- �-- ----------------- - •----- --- --
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
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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IF N89°56'32"W 306.18' TOTAL IS � 57.53' /
— — — — — — — — — — — NF
IS IS
N88'33'43"E
134.42'
0
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0
O N
W �
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w �
N J
2� � �
----- S
248.65' �
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S89°56'32"E 277.58' TOTAL IS � ti NF ��
221.66' S5.92' NS
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,
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1 . 97 AC . � � �
STONE
FOUND
127.59'
S88°38'42"W
IF
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NCGS "OLD WELL" O i
N=940098.349
E=1983488.852 NS �
CONTROL /
CORNER
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/ ryry � /
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>>>.44' IS
N82"48'33'�w 51.78' /
163.22' i NF �
TOTAL � �
/ / /
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IF Ngg•56'32"W 306.18' TOTAL IS � 57.53' NF /
----------- 248.65' i
i
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IS �N88'33'43"E IS S89°56'32"E 277.58' TOTAL IS � n, NF ��
�� 134.42' ���� 221.66' 55.92' NS
��,�¢i �
,+,y �,�,;. ,
,, _ /
`'' ' t ` � �
45' ._ �� o � � �
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Z 1 . 97 AC . ' � /
o �� / o
N da.5 e �
v oNo S�+� NCGS "OLD WELL" O i
W � _ N=940098.349 NS �
n� � � E=1983488.852
21 � � �n�y,� ' CONTROL /
�. � f
CORNER
� ��� � �' ,�N �[�, t?j$��i-
,2�� ��n I�h r � �, �. � i
,��5 „���—v ���,Cj / � � � �
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IC o n v�n, �--� o,n ct... � ��.
�G��� i'`}�dtSTONE i �/ hN . /.
/ � i
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I,----_ TT7-59 '
S88°38'42"W � � i
IS � 111.44� IS , �
IF 5� �8 /
� N82 ° 4 g� 33 �� yy
` � 163.22' i NF
' � jOTAL � ��
. I I
` I / / /
I � / ,
11�13/1997 09:31 80445�7843 BENNEfT WELLDRIL�.ING
t2-��1-199.� �1A��l9►�t'1 FRCI". pt��� ��.�'Iti �E�'.TH,:�P� t�-`
1� ate: �� �� L�. ; ��. 7 .:., '
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�..�Catiqnl�ir tions:
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l�A�pN CQu?i7Y �ltVt�l4Kt��NT�L itCnL'[N
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t�isc�ce fso� Ne�rest �optrry Lin��_,_,,,,, ,,; ���yx;e fr�m a�outse of
Fai�u�iori �
Ta�l D�p�:,�.�„�„ Ft. Yi��d:�,� �P�� St�t�� Watet ixv�t Ft.
W��t= ��tdt� Zon�s: I�tgc�t „�,,.w._,�,�t.,,,.._�.,,,_.,��,..,�..�.....��._,,,,� .����._._.,.....�....�..
Cxsi�t�: I�cpth: �rotn,,,..�,�_„_ta�t. ptun�tar;_ .� �.� _Izisher
TYP�: $ta�el Galv,►,it.excd Staal ►..�
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3� St+�l, doe� owner �pp�cov�: Ycs�„No�_
Wa�gh�:� �' ,,,,r 't'hickllt�s;,,��,,, ��i�t A'h�vc CrOtu�d �, ,��, Inches
�ivC si`tC�: ��S__,� „^ r�p � .
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I� "y�s'' g� �++� r�e�►san:..,.,� _ `�"�.'_
�tout: '�'ype: Ntat. ✓__ , �, $xndJ�`er��s�t CancrEtc "~'--�
Ar�riulu.5pace Width 62.. � /� t •°—. --.,---_
r 1��� Yw�l`-����I��i
Wat�r in Annulu Sp�ca: Yes�,�,,,,, Na�.,,,
Nt��tod; P�urnged�,�, �re�su:�e�_ pcurcd�
X}epth: Fram_--., C� �—_ t� !� F�.
Nluaria�s U#�d: No. $�gs Portl�� �emcnt�,,,�,�„„ i�eig�t Qf 16ag,�.,��b,
�f m�x�ue (s�,nd� �raye�. Cu�dri$S� - �a�r;v:` �, _ ��,��
IU Pl:tcs: Ycs.,�v..�, No.,�„�_
i H�REBY C�R'1"'�PY THAT 7HE /��YE INFpRIY1r�TIC�N I$ C:t7RR E�F A[tiD Tl-Ip
THIS w��,L WAS C0�57'RUCT�D xN A�C�R1'aANCE V�T� �ErULATIONS ;�E
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