A30 114v - -
Amount paid v2�d�' .
Receipt li ' �j6 .� � �/ 9�
- � Date
_ . . �I76`7 - - -----
Bacteria
1. Permit requested by:
owner/prospect ve ow �
Address: _•� a
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me Phone #:
_ Chemical
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F
usiness Phone #: �,��,1�4_
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_ Petroleum � _ Pesticide � _ Lead
7. Dimensions or Proposed Structure:
W idth:
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is iniended to serve?
.s'99 �9.s.y, .
and ad�d� es of cunent owner. 9. Water suppl } pe: -�
� �%�/.�,�.� �'��,v �� � private . ublic ❑ community ❑ spring ❑
� Are any wells on adjoining property?Yes ❑ I�Io �.
If so, identify location:
n: Lot size•
Tax Map#: . �
Parcel#: J�
Tn�vnc}iin• .
. Directions to propercy: State Road #& Road
I�Iumber of occupants or people to be served:
I0. Type of structurelfacility: Proposed: �Existing: Q
Type of dwelling:
House: � Mobile Home: usiness: ❑ '
'�ype of business•
Number of Employees:
umber of bedrooms: �._
Garbage Disposal? Yes ❑ No -
Basement? Yes ❑ I10 so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AI�tD THE CORTIERS OF ALL
PROPOSED STRUCTIJRES.
�I hereby make application to the Person COunty Tdealth Department for a site evaluation foc the on-site
sewage disposal system for the above described propercy. 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 �
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have no�
delivered a survey plat of the pcoperty to the Health Dept. within 60 DAYS after the date of the evaluation of
thesite by the Health Dept., this application shall become void and all fees paid forfeited.
Sienc3 Owner or Authorized Agent
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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 # -�i 3(? Parcel # � �`T
Zoning Township � j (,t S h l/ r
Owner/Contractor .J��,�a I
Location/Address � 45 � ,
Subdivision Name ��� ; � 1 D �J Lc� k� Lot#,
Date 5'C —17 —
� --�'" ��O �` ✓lG� eX(f.r �%
S.R.# �''
SEWAGE SYSTEM SPECIFICATIONS
Repair ✓ Lot Area 1. ��C� Size of Tank l�� �
C
SFD ✓� Mobile Home �� Size of Pump Tank
Business # of Bedrooms � Nitrification Line C.� (�O `x 3�
Max Depth Trenches � � f
Permits may be voided if site
Well and Septic Layout by
Comments: �h,ll �
or inteny�ed use changed.
Date Y/�?%� Installed by,,�l1Y�'vYYt.�.a- ��.�Q. Approved by
�°�- `3-1 -�S�' S•�
Well Permit Paid WELL SYSTEM 5PECIFICATIONS
Individual V Semi-Public Required Slab
Public Replacement Air Vent
Site Approved Required Well
Well Head Approved `� . Well Tagi�
Grouting Approved � � �--�-jj�p h �
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 information
contai�ed 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
.• • AUTHORIZATION rOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: �� � — �� IlVIPROVEMENT PERNIIT #: �
TAX MAP #: PARCEL #: ��_
OWNER/OWNER'S REPRESENTATIVE: � �(�.I(� �S�,L.�°a,
LOCATION/ADDRESS:
SUBDIVISION NAME: �� I I U L�J �I�Q LOT #:
SECTION OR BLOCK:
AUTHORIZATION FOR CONSTRUCTION ISSUED 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 Pernut #�. The
constn.iction 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 pernuts.
4. Conditions:
Person Requesting: � a�I �� I� i`
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Owner:
Location/Directions:
,.. . ._. ,. _ .-
PERSON COUNTY ENVIRONMEHTAL HEALTH
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WELL LOG
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Subdivision Nv�ne: ._ T.LL� A�— Lot #
Drilling Contractor: � �,
WELL CONSTRUCI'ION
Distance from Nearest Property Line 10 Distance from Source of
Pollution loo `
Total Dep.th:�l.�Q _ Ft. Yield:�o___ GPM Static Water L,evel��_Ft.
Water Bearing Zones: Depth�p y�Ft.�(_o_-�,�F� Ft� �t.
Casing: Depth: From O co_��_Ft. Diameter:� j� Inches
TYPE: Steel � Galvanized Steel �"
If Steel, does owner approve: Yes No
� Weight: Thickness: , l8� HeighCAbove Ground: l�{ Inches
I?rive Shoe: Yes � No
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" give reason:
Grout: Type: Neat Sand/Cerrlent � Coricrete
Aruiular Space Width Inches
Water in Annular Space; Yes No
- -. �ethod: Pumped - _ Pressure � Poured �-" �. � - �. _ -
Depth: Fr�m � co z C� Ft. -
Materials Used: No. Bags Portland Cemenc Weight of .1 bag__lbs.
If mixture (sand, gravel; cuttings) - Ratio: co
-ID Plates: Yes � No � � �� �
�� 4 x 4 slab Yes—�No
I HEREBY CERTIFY THAT THE ABOVE 1NFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C�ui�ITY HEALTH DEPARTMENT.
q � 98 -----
ignature of Contractor Datc
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