A30 1060
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PERSON COUNTY HEALTH DEPARTMENT
' WELL AND SE�'AGE vITE, LOCATION IlVIPROVEMEr1T PERNIIT
,B1122
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system co�struction
has been issued.
Tax Map # A SU Parcel # lb�
Zoning Township �usN Y Fis x�k
Owner/Contractor �j.�� � L, � ��L/1 L of K Date C— i i- � C
Location/Address �,,� y� ,5 i/ o,�/ ���ss E_�L f/a.�Tc�n/ �D�
Lo T dn/ �P / G-,y i S.R.# �
Subdivision Name ����i� ,�L A LOG%G Lot# �
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area Size of Tank /liCt� G/-� �
SFD Mobile Home Size of Pump Tank �l fA
Business # of Bedrooms�_ Nitrification Line �Do' X 3�
. Max Depth Trenches z� '� z 5� "
Permits may be voided if site is
Well and Septic Layout by�
Comments: �./�� ,� � ���r_
G
or intended use ch
/
Date �-r8- �'j6 Installed by �iun.� � 1c�J'! Approved by
A�{ c=Ei� %.'1 I�A`i
ell Permit Paid ❑ WELL SYSTEM SPECIFICATIONS
Individual �/ Semi-Public
Site Approved i
Well Head Approved_
Grouting Approved_
Comments:
Installed by
Required Slab �
Air Vent
Required Well Lo� �/
Well Tag _ j�
� Approved by
This report is based in part on information provided the homeowner or his�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
�'�UTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: //- � - 5'6 IMPROVEMENT PERNIIT #: �/�Z
TAX MAP #: � � PARCEL #: /� G
OWNER/OWNER'S REPRESENTATIVE: �.v.�,� uC ,u.� .a i°� � cc �3G /-� ��cl�
LOCATION/ADDRESS:
�/9 S�vi ,-/ o�/ h�A SSCGL .��a� Tn�.1 � r�
/ t� T /s vnl Iz / � /� %
SUBDIVISION NAME:Iy,c�,� L�� �'G�4 L v C_I< LOT #: �
SECTION OR BLOCK:
AUTHORIZATION FOR CONST�RIJCTION I>SSUED BY:
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 Permit #,r�//ZZ. The
construction and installation must also meet all 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
permit and application, may void this authorization and associated permits.
4. Conditions:
/���/J L�� � s a..t �ns TO c�iZ
LG -� y �� riI /� x % 1Z � t�' c N- �c l� l/�
Person Requesting:
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