A30 115Amount paid
Receipt fi
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Improvements Permit.(Established/Recorded L,ot)
ls Permi[ lUn�ecorded Lot)
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Date
Reinspection of Existing System (Loan Closing)
_ Repair/Replace existing Septic System
tmprovements Pecmit (Mobile Home Replace) _ Permit for New Well
Improvements Permit (Addition) _ Replace Existing Well
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Bacteria _Chemical Petroleum Pesticide
1. Permit requested by: .
ownedprospect ve ow er! gent:(
Addcess: •�' Q v s
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ome Phone #: .s�f7—i�,7� ,�99 i�%Sy'
usiness Phone #: ���9 ��4
I�Iame and add es7C of current owner.
�rr� 1� %��i,V. � / ` �/'l�,!/l/1G ��
Descrintion: Lot size:
Tax Mag#: ,i�'�D �
Parcel#: � � � �
. Directions to propercy: State Road #& Road
I�Iumber of occupants or people to be senred:
7. Dimensions or Proposed Structure:
Width:
_ Lead
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?
9. Water suppl ype: - -
private ublic ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No Q.
;If so, identify location:
10. Type of structurelfacility: Proposed: �Existing: Q
Type of dwelling:
House: � Mobile Home: usiness: ❑
�ype of business•
Number of Employees:
�dumber of bedrooms: .�_
Garbage Disposal? Yes ❑ No
Basement? Yes ❑ No so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY Ai�ID THE CORI�IERS OF ALL
PROPOSEDSTRUCTURES.
�I hereby make application to the Person COunty Health Depat'tment for a site evaluation for the on-sitf
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 �
issued, I must present a survey plat of the property to the Healch Dept. I understand that in the event I have not
delivered a survey plat of lhe property to the Health Dept. within 60 DAYS aftec the date of the evaluation of
the site by the Health Dep�, this application shall become void and all fees paid forfeited.
Siencc� Owne� or Authorized AQent
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B 2473
� PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT 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 # �� 0 Parcel # � ��
Zoning Township L��{1 C'�
Owner/Contractor d Date — � �—
.I.Qcation/Address QS � �� �c.t nQ � Q Pp � �n � .� . %�� � �
Subdivisiori Name
S.R.# �� �q _
Loc# 2
SEWAGE SYSTEM SPECIFICATIONS
Lot Area�. �D �
1�1G1obile Home �-
# of Bedrooms�_
Permits may be voided
Well and Se tic Layout 1
Comments: ��1�.,8.t�
Date
ell
altered
Size of Tank l bOC
Size of Pump Tank_
Nitrification Line ��
Max Depth Trenches
ed use
" �Installed by Approved by
I �5' � 02 - - °I
Paid ELL SYSTEM SPECIFICATIONS
Lr Semi-Public_
Replacement
te Approved
ell Head Approved
�outing Approved_
Comments:
Date
Installed by.
Required Slab _
Air Vent
Required Well Log
Well Tag
Approved by
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This report is based in part on information provided the homeowner or his/her
representative in the application submitted for tnis 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
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AUTHORIZATIOI�I FOR WASTEWATER SYSTEM CONSTRUCTIOI�I
(Void sixty (60) months from date of issuance)
DATE: Q-� � �—Q � IlvIPROVEIviENT PER.MIT #: 7
TAX MAP #: �; PARCEL #: J I S
OWNER/OWNER'S REPRESENTATIVE: � ��V �C� li—'f'�f('� I
T—
LOCATION/ADDRESS:
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SUBDIVISION I�IAIv�:
SECTIOI�I OR BLOCK:
.
AUTHORIZATION FOR COI�ISTRUCTIOI�t ISSLJEI�,,BY:
AUT'fiORIZATI02�I CONDITIONS
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LOT #: �—
I. The Wastewater system construction and installation must meet aIl of the conditions of the
attached site plan and specifrcations as set forth in Improvements Pernut #_����3. The
construction and installaiion must also meet aII applicabie rules and laws.
2. I�Io portion of the Wastewater system shall be covered or placed into use until inspected and
appcoved by the Person County Health Department. �
3. Any aiterations in site or soii conditions Cnciuding structure locations) or modification in use,
design wastewater flow, or wastewater characteastics as speci&ed in the associated improvement
permit and application, may void this authorization and associated permits.
4. Conditions:
Person Requesting:
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PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG '
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Subdivision Name: __ Lot #
Drilling Contractor: (,�. .
. � WELL CONSTRUCTI
Distance from Nearest Properry Line /� Distance from Source of
Pollution !DO `
Total D� th:� U —
._�p. �_ Ft. Yield: oZU GPM Static Water Level 0?�5 Ft.
Water $earing Zones: D�epth,���Ft. / 1� F� � Ft� ��.
Casing: Depth: From O to�Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel �/
If Steel, does owner approve: Y�s No
� Weight: � Thickness: /� Height`Above Ground: < ti Inches
Drive Shoe: Yes ✓ No
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" give r�ason:
Grout: Type: Neat Sand/Cement ,/ Concrete
Annular. Space Width Inches
Water in Annular Space: Yes No
_ .. Iulethod: Pumped � - - � -Pressure - � Poured-✓ � �' �- � � • •, - : .
Depth: From O to �, � Ft. � �
Materials 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 �
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I HEREBY CERTIFY THAT THE ABOVE INFORMr�TION IS CORRECT AND THAT
T�S WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSO�I C�Ui�'1'y HEALTH DEPARTMENT. �
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�S gnature of Contractor D1t�
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