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Permit. (Established/Recorded Lot)
ImpFovements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
ments Permit (Addition)
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_ Reinspection of Existing System (Loan Closing)
existing Septic System
for New Well �)( j
Existing Well
1. Permit requested by: . ; 7. Dimensions or Proposed Structure: ,
owner/prospective owner/agent c 1� Width: ��t _ y1r�(�i e_.� �-
� aa..e��. lA� t� 1�na� �- .�c �c� - Depth: �b
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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?
ome Phone #: (�I ► 0) 5`�`1 ��
usiness Phone #: �4—
and address of current owner: 9. Wat r supply type:
,� - � � � �,� c� private f, . public ❑ community ❑ sp ' g ❑
� Are any wells on adjoining property?Yes No j�.
,��„ �,,� �\ � '\-7 �-� If so, identify location: t� WDD �S � C..i�
. Property Description: Lot
. Tax Map#:
Parcel#: _
Directions to property: State Road #& Road
�e;�tc4Q L a-,� �� J���le.._ R�
Number of occupants or people to be served:
10. Type of structurelfacility: Proposed: �lExisting: Q
Type of dwelling:
House: ❑ Mobile Home•� Business: ❑
Type of business:
Number of Employees:
Number of bedcooms:
Garbage Disposal? Y �❑, �No
Basement? Yes ❑ Nol�1 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 PerSOn 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 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.
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Signcc� Owner or Authorized Agent.
Permit Issued ❑ Signature GVIi Date
Permit Denied ❑ _ __. " '
Plat Observed❑ _._..__- : _ =-- � : , �.
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1. SLOPE (%) S S 5 S
PS �.. , j� PS PS PS
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2. SOIL.7'EXiVRE(12•361N.) S /� S S S
(SANDY. LOAMY. CLAYEY. NOTE 2:1 CLAI� . S /_ Y� PS PS PS
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3. SOiL S77tUCfl1RE (12•161N.) S S S S
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d. SOILDEPiii(WJ S S S S
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3. RESTRICTIVEHORiZONS(iN.) S 5 S
(IMPERVIOUS STRATA, ROCK) PS PS PS
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6. SOT[.DRAINAGF/GROIJNDWATER S S S S
�p(T��, � Q�N�� S PS PS PS
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7. SOII.PERMFJ1811SfY S S S S
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A. AVAILABLESPACE S S S S.
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9. STIECLASSIFIGTION(SEEBELOW) S
SO1L SFRIES '
S-SUITAIILE PS-PROVLSIONALLYSIJ[TA6I.E U-IJNSUITABLE
RECOMMENDATIONS/COMMENTS:
STTE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns� CIC.� C:UMfPR04DOCSAPPSEC.S�4 FWANCE.PC
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B 1576
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION I1V�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 been issued.
Tax Map # , a I Parcel # �v 2
Z011lilg TOWriS�11U (� 11�1�� /r��
Owner/Contractor � (�r l Ye,�n Date 3-� �/-9`7
Location/Address S 6 2 Srt -�ry /� ��� � 2�
v �1� rr� ✓w� ot� o.t I Q �' '� � e1�Aw %�S.R.# / J�
Subdivision Name Lo #
�`� f � ' � SEWAGE SYSTEM SPECIFICATIONS
Re air Lot Area S�l a C✓e �ii rM Size of Tank n f
SFD Mobile Home � Size of Pump Tank ���
Business # of Bedrooms 3 Nitrification Line �()v 3
Ma�c Depth Trenches -2 � "
Permits may be voided if site is a
Well and Septic Layout by
Comments:
Date �I _2- �'t % Installed by=
Well Permit Paid ❑ W
Individual S -Public
Public eplaceme
Site Approved
Well Hea pproved
Grouti Approved
Co ents:
Date Installed by�
rt�nded use changed.
� () D�—��
t S Approved by
SPECIFICATIONS
Requi lab
ent
equired Well L _
_ Well Tag
�pproved by,
This`re�po�t 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
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:\amiprolpermit.sam O1/95 rev.l.l
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AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
� (Void sixty (60) months from date of issuance)
DATE: 3- a y-�j rI IlVIPROVEMENT PERNIIT #: /�%
: TAX MAP #: PARCEL #:
OWNER/OWNER'S REPRESENTATIVE: R i° � �c� 1nJ�f'er��
LOCATION/ADDRESS:
S-f�n S 1?� 11 G, 2�b srt .� I r�� .-14 �,;Lo ori CD ¢ f �.•
SUBDIVISION NAME:
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 # Q/5`7�. The
construction and installation must also meet alI 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
pernut and application, may void this authorization and associated permits.
- 4. Conditions:
Person Requesting: