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Improvements Permit (EstablishedlRecorded Lot) I_ Reinspection of Existing System (Loan Closing)
Improvements Pernut (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
Repair/Replace existing Septic System
Permit for New Well
✓ Replace Existing Well
_ Bacteria l _ Chemical I Petroleum I _ Pesticide � _ Lead
1. Permit requested by: �, � �, I� 7. Dimensions or Proposed Structure:
owner rospective owner/agent:� r�t/1CiS r( Width:
ddress: �3 �� pL ���r L.,�v,a �c'o�� Depth:
•� ' C' ? 3 8. What type (if any, additions, expansions, or
� replacement is anticipated to the structure or facility
�, r that this sewage disposal system is intended to serve?
, ome Phone #: � "�y %- ��?
� usiness Phone #:�l� - �� 7� � :zf6
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2. Name and address of current owner: 9. Water supply type:
private ❑ public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No ❑
If so, identify location:
3. Property Description: Lot size:
. Tax Map#: 10. Type of structure/facility: Proposed: ❑Existing: ❑
Parcel#: Type of dwelling:
Township: House: ❑ Mobile Home: ❑ Business: ❑
i 5. Directions to property: State Road #& Road Type of business:
� ames, etc. Number of Employees: -
� Number of bedrooms:
y Garbage Disposal? Yes ❑ No ❑
' Basement? Yes ❑ No ❑ If so, # of basement fixtures:
I6. Number of occupants or people to be served:
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CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pet'SOn COtlnty Health Depat'tment 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 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.
Signed Ow�n,er or Authorized Agent
a .. .
1 t /.,.
Permit Issued ❑ Signature Date
Permit Denied ❑
Plat Observed ❑
PACtORS-SREBVALVkTION ' ;ARFA1 AREA2 ;:: AREil3 `.:.AREA�i
l. SIAPE(9E) . S __:. S ..._ 5::.. . ... ...: S ..::. ..::.:
PS PS PS PS
U U U U
2. SOIL 7EXNRE (12-36IN.) S S S S
(SANDY, LOAAfY, CLAYEY, NOIE 2:1 CLA1� PS PS PS PS
U U U U
3. SOIC. S7RUCIURE (12-36 lN.) S S S S
(CLAYEY SOILS) PS PS PS PS
U U U U
4. SOIL DEP71-I (IN.) S S S S
PS PS PS PS
U U U U
S. RESTRICTIVE HORIZANS (IN.) 5 S S S
(AIPERViOUSSTAATA,ROCK) PS PS - PS PS
U U U U
6. SOILDRAINAGE/GROUNDWATER S S S S
(EX7ERNAL & WTERNAL) PS PS PS PS
U U U U
7. SOIL PERHIEABILITY S S S S
(PERCOLOATION RATE) PS PS PS PS
U U U U
8. AVAILABLE SPACE S S S S
PS PS PS PS
U U U U
9. S[7E CLASSiFICATION(SEE BELOW)
SOIL SERiES
S-SUITABLE PS-PROVISIONALLY SUITABLE 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:WNIPRO�DOCSIAPPSEC.SM FINANCE.PC
_.- Vi� � �e���'� 0-1(� A 0* 6 8
PERSON CO�TY " '
HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMI'R VEMENT PERMIT
Tax Map # �Z9 Parcel # ��
Zoning Township
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Owner/Contractor - Date _ '7— S'— ��'
Location/Address _
� S.R.#
Subdivision Name Lot# /' J,f, �� ��P � ,
SFD
SEWAGE SYSTEM SPECIFICATIONS
Lot Area Size of Tank ��� ��j� ��
Mobile Home Size of Pump Tank T�r
# of Bedrooms Nitrification Line
Max Depth Trenches
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is alte d or intended use changed.
Well Layout by ���—
Comments:
Date Installed by Approved by
�� � 1-{�� N`�' , WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab
Public Replacement Air Vent
Site Approved �/ Required Well Lo�
Well Head Approved Well Tag
Grouting Approved
Comments:
Date Installed by
Approved by
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 infocmation 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 &om false or misleading
statements provided to him in the appiication. Neither Pecson County nor the environmental health specialist wartants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�pernritsam O1/95 rev.1.0
ORIGINAL