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PERSUN COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
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 # /� - 3 v Parcel # � o g
Zoning � _ . L. � . � � Townshi ,�v.; N Y F"� � X
�ba.t 10 �'
Owner/Contractor -� •�-e -- � � -- Date �T�/9G
Location/Address g� s�95 T C o-� �s/.����u .��.z���_ �D
S�D o.V �i � � — S.R.# ���v�
ision Name G'i�r4 ri �, � � ��. c.o c,e Lot# �
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area . o� �4G Size of Tank /� l,¢�-
SFD Mobile Home Size of Pump Tank�c/%
Business # of Bedrooms _ � Ntrification Line ��� ` sr ,� ' _
Max Depth Trenches ,�o `'-zy ' '
Permits may be voided if site is altered or intended
Well and Septic Layout by /�'�� 4° G���,�
Comments: �-co ° y 3' �cli i rz� F-i ��_Tio,
�
FocLo�� �/2v��.eT� LjN6'. .<,ts� s'o�c�w
(Date 12 -20- 9 G Installed by ��. _ ow,' Approved by
�F � ia- ��
Well Permit Paid �� WELL YSTEM SPECIFICATIONS
dividual (/ Semi-Public Required Slab ✓
�blic eplacement Air Vent
te Approved Required Well Log
ell Head Approved � Well Tag
Comments:
Date�/h 7 Installed by ,!l �3tt�z.ciE� Approved by
0
Y �! uS j
G�1/ Gt�/cf
This report is b�sed 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 �alse or misleading information
contained in the application. The environmen�al hea�th 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:lamiprolpermit.sam O1/95 rev.l.l
. �
., AUTHORIZATION FOR WASTEWATER SYSTEM LONSTRUCTION
� (Void sixty (60) months from date of issuance)
DATE: 6
TAX MAP #: A - 3a
IlVIPROVEMENT PERMIT #: ,t3 /�r`Sa
PARCEL #: /vg
OWNER/OWNER'S REPRESENTATIVE: C'E�AfruE ,r3c�a�o�i�
LOCATION/ADDRESS:
s-- i/� a,v
S�D b.cd �fi7�-/� /'_
LL
SUBDIVISION NAME: G�` �.a,��lC .d «�v c� LOT #: �
SECTION OR BLOCK:
AUTHORIZATION FOR CONSTRUCTION ISSUED BY:
�� � ��- c �
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 Permit #_,g �ygg 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 Iocations) 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:
SOO � X 3� �/ i�� F I G�} i! U�/ L�N C - �OLLbc...J
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Person Requesting:
DEC 10 '96 1�:�1 .
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�* TOTpL PAGE.002 �**
�an-09-9� 1Oz15A Barnette we77 Co_ 910 599 0015
• � - . PERSOH COUNTY ENVIRUNHENTAL IIEALTH•
' _ .
Date: /-�'- 5 7 '
Owner. �� �� f, �
LocationjDirections:
Subdi�ision Name:
Drilling ContracLor:.
GI$LL �,OG ' �
n
SR#
• P.O1
Lot #�
----___
Distance from Nearest Property Line �b`�— Dist.ance from Source of
Pollution �� `�- '
Total.Dep�h:- f Ur� Ft. Yield:�� GPM Static Water Level a?�F�
V4�ater Beazing Zones: Depth �Ft�3 F�. � Ft� �t.
Casing: Depth: From,.�._to��_Ft. Diameter:_ Q y Inches
TYPE: Steel � GalvaniZed Steel ----
If Steel, daes owner approve: Y�s I�Io
Weight � Thickness:�_ Height`Above Ground:_�4� Inches
Drive Shae; Yes ✓ No
Were F�rvblems Encou�ntered � Setting the Casing? Yes No .-�
�f "yes" give r4ason:
Grout: Type: Neat Sand/Ceme,nt ..-- Concrete
Annular Space Width Inches
�ater in Arn�ular Space: 'Yes No
_ -. Method: Pumped Pressure . - I'oured ✓ . . -
Depth: From C,� :o_,� Ft.
Materials Use�i: No. Bags Portland Cement Weight of _I bag��lbs.
If mixture (sand, gravel; cuttingsj - Ratio: to
ID Piates: Yes ✓ No � �
4 x 4 slab Yes r Na
I HEREBY CERTIFYTHATTHE AB4VEINFOR]VIA�['XpN 1S CQRRECI' �II�THAT
THIS WELL 1�AS C�NS'I'RUCTED II�i ACCORDANCE WITH REGULATTONS SET
FQ�TH BY THE PERSO�t CO'JiJTY HEALTH DEPAR�'MENT.
��'!�� ,e��f - -- -
Signaturc of Contractor Da:�