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� �6. Number of occupants or people to be served: �_� �
� CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
� PROPOSED STRUCTURES.
� I hereby make application to the Pet'SOn COunty F�ealth Department for a site evaluation for the on-site
,� sewage disposal system for the above described property. I agree that ttie contents of this application are tcue
�� and represent the maximum facilities to be placed on the propercy. I understand if the site is altered or the
�ntended use changes, the permit shall become invalid. I understand that before an Improvements Permi[ can be
issued, I must present a survey plat of the propeny to the Health Dept. I understand that in the event I have not
delivered a sucvey plat of the property to the Health Dept. within GO DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
Amoun t pa id ��6 roo
Receipt !� ' a p �
. . � �7,�6 �
'�rr,�;rovements Permit.(Established/Recorded Lot)
3-1���
Date
�:x :, y r`-r 1 c n-s�l .
.. . .,%a ....�..r�..w-aYia':t ._-.
Reinspection of Existing System (Loan Closing)
��'_:mt�ovements Permit (Unrecorded Lot) aidReplace existing Septic System
� Improvements Permit (Mobile Home Replace) Permit for New We(1
Improvements Permit (Addition) _ Replace Existing Well
l. Permit requested by:
ner/prospective own
Home Phone #: .S
Business Phone #:
N
�e�. l.{,�,j-'j-i�IQtVj 7. Dimen ion� or Proposed Strucwre:
� k
nt: `,1t�.�a� Width: _�
Z���/t� ���, �-' J Depth: ���
_ � ��--
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this se�va e disposal system is intended to serve?
and address of current ow er: � 9. Wate upply t}•pe:
? � �� � t � ` � , private�. public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes� No [�.
If so, identify location: '���QQ '
. Property Description: Lo[ size: "��i�
. Tax Map#: 3d
Parcel#: I 3
Township: �"
. Directions to property: State Road #& Road
�3�
L�T1
10. Type of structurelfacility: Proposed: DExisting: Q
Type of dwelling:
House: ❑ Mobile Home:�Business: ❑
Type of business:
Numbec of Employees:
Number of bedrooms:
Garbage Disposal? Yes ❑ No
Basement? Yes ❑ No�1 If so, # of basement fixtures:
�.:
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g 2822
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT 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 # �3Q Parcel # � 3
Zoning Township t
Owner/Contractor �p p � nP L� -N-� _ Date 3-�3—�Q
Location/Address t--} Q�T�_—�j h✓� len � T�L Q-��=- ���'-r
S.R.#
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area • o G
SFD L� Mobile Home �
Business # of Bedrooms 3
Permits may be voided if s' 's altered or in
Well and Septic Layout by
Comments: �Q � i � �
Date.g �L(o- y 9 Installed
Size of Tank �(� � w� �
Size of Pump Tank
Nitrification Line �{�n` )C 3'�
Max Depth Trenches Zp''
;��H �-to � �msi(�
nded use changed.
Approved by.
ell Permit Paid [� WELL SYSTEM SPECIFICATIONS
3ividual �Semi-Public Required Slab ✓
iblic Replacement Air Vent ,/
te Approved ✓ Required Well Log �/
ell Head Approved v Well Tag ,
-outing Approved � �}` �y'q q ��� 1-�as� ��' '�
�
Comments:
Date y- �/-99 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 information
cootained 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 Ol/95 rev.l.l
, AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
� (Void sixty (60) months from date of issuance)
DATE: �J � -Q �
TAX MAP #: ��
IlV�ROVEMENT PERMIT #: o� o
PARCEL #: l �J
OWIVER/OWNER'S REPRESENTATIVE: 1��(� V'1C'_ �-�1-��
LOCATION/ADDRESS:
SUBDIVISION NAME:
SECTION OR BLOCK:
FOR
T
ISSUED BY:
AUTHORIZATION
LOT #:
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 #�, 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 Coumy Health Department.
3. Any aherations in site or soil conditions (including structure locations) or modificarion 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:
Schedule 40 solid pipe over dams Keep septic 100 feet from any well 10 feet from anv
prape*� line 15 feet from basemeYrt wall 5 feet from anypart of the house. Keea well at
least 25 feet from any foundation and 10 feet from anyvrope*�y line
Person Requesting: �% � Yi �I � �
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MARGIE EVELYN PASS
D.B. 215, P. �
IS
_ _ :. . .. :__ _ _.
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� � = PERSON COUNTY ENVIRONMENTAL HEALTH
• • � . �� _ e:
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� • •• WELL LOG ' . ,
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Date.
Own�
Loca
=Yr ' �� ( � ,
Subdivision �Name: � �� � �
Drilling Conrractor:
llistance from Nearest Property Line /U Distance from Source of
Pollution �DO `
Total Dep.th:� /7D Ft. Yield: ,3 GPM Static Water Level S Ft.
Water Bearing Zones: D�epth 3.� Ft. � Ft� � F� �'t.
Casing: Depth: From�_to �S'L( Ft. Diameter: Inches
TYPE: Steel - Galvanized Steel �
If Steel, does owner approve: Yes No
� Weight: � Thickness: /� Height�Above Ground: < t� Inches
Drive Shoe: Yes ✓ No
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" gi�e reason:
Grout: Type: Neat Sand/Cement ,/ Coricre[e
Annular. Space Width Inches
Water in Annular Space; Yes No
_ . Method: Pumped _ . �Pr�ssure � - Roured ✓ �-- �. � � • •: - ..
Depth: From O to �. � Ft. � �
Matenals Used: No. Bags Portland Cement Weight of .1 bag,__lbs.
If mixtuie (sand, gravel; cuttings) - Ratio: to
�ID Plates: Yes ✓ No � � � •� � �
�� 4 x 4 slab Yes—�_No �
J
:
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I HEREBY CERTTFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
T�S WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORZ'H �y.THE PERSON C�Li�ITY HEALTH DEPARTMENT. �
,._.� �. -
Signaturc of Contractor Dace
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(�,� S��'�s �
S��c
Appiication i3ate: � a� ��
�mount l�aid: 1�3
Rec�iut �#• 2 �� � �
: '���; �� ���� ��
- - _ _ � � ����
�Eaa�-aa-�aa�^^• oa�.ml1 ?E-�C��.Il��a
EiPP�ICATIOfd Ft3R SE3iVIC�S
i ax iUlap �. � 3 Q
Parcal �: � � 3
l� T}-DE IN�ORIVI�►TIO(t� 16� TiHE e4PPLICAT90P! F�06� .�1i� IMP�i�VEMEAlT P�'RIIAIT �S IiVCOP�RE�T. F�LSI�aED,
CNAI�GE� OR THE SiTE !S ALTERED i�EN T9-BE liiliPt�OliEilfiENT PERf�iIT AND AllTH�RIZ�ATION Tt3
COMST�2UCT SHALL BE�OME IfVVA►LID. �
1) Permit rea�u�t ���w COvvner/agentlprospective owner): ��/�� �� ���"
Home Phone: 59 - 307 7 Address: 3 S�yH /�u..E,� p,
Business Phone: - Zo50 Kr�cBo!'o � n(G Z�57�{
, 2)
3j
Narree and ac8dress of current owrner: �144� �Rj�/�l�- ��f�-�
o LLFc� !
nXi�oRo, �tlC 27S7y
� �� �
Property Desc�ptcon: Lot size: ��Z`� Township: Subdivision: Lot #
Directions to the property_(Includ�n� road names and numbers): _ _
7 f:i �'B/ m/�r�3ox .
4) Propos�c8 Use arad Structur� Description: answer each of the following questions:
a) Proposed �, Existing �, Type of Structure: #-�OJS� i�J�LGi•�1 � Width: Z� Depth: � v
b) Number of Bedrooms: Number of occupan st or people to be served: 3
c) Basement Yes_, No � Will there be plumbing in the basement?
d) 6arbage Disposal: Yes , Nq'� '
5) !f�later Supply Type: Private �/ (new _ or xisti �, Public_, Community , Spring _
Are any welis on adjoining property? Yes No _ If yes, please indicate approximate location on the
'site plan.
6) Does your property �ontain g�rebiously identifaes! ju�isdiciional wei9ands? Yes_ No �
PLEASIE �IOTE TFiE FOLl.OV!►IIdG:
9 a� PL.�►T �F Ti-1!E �ROPEiaTI( OR SITE PLAi� MUST BE SUBMI�TE� IAIITH THIS 9►PPLlC�TI()iN.
➢ PROPERTY LDPIES Ai�ID CORNERS MUST BE CLF�RLY MARKED. -,
9 Ti-!E PROPOSED L�CATIOId OF ALL STRUCTURES i1flUST SE ST�►K�D OR �LAGGE�.
9 TDiE SITE fVIUST �E i2EADILY ACCESSIBLE �'OR AW EV�4LUATION �'t "i{-iE �iE�►LTH �EP�►RTiiflE�IT
S"iAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-siie sewage disposai
system for the above-described property. I agree that the contents of this application are true and rzpresent the maximum
faciiiiies to be p�laced on the property. I understand ifi the site is altered or the intended use ct�anges, the permit shall
become invalica� . , ,-----�
Cwner or Legal
`�- Z 2 -2�5
Date
PCHD, rev. 06127/02
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MARGIE EVELYN PASS CHANDLER � t-
D.B. 215, P. 827 � I i
S88°20'54"E
110.03'
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315.46' TOTAL IF �
30.97� NF �
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D.6, 269, P. 192 �
P.C. 10, P. 79-H '
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