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Amount. paid ��d�' �� 9�
•Receipt ll '_ 176 Date
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1, permit requested by: .
owner/prospect ve ow er/ gent:C
Address: �� a� - � ;
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ome Phone #: .s9�—��� .�99 �%sy'
usiness Phone #: ��2�,—,1,�4_
. Name and add�re&� of cucrent owner.�._____
7. Dimensions or Proposed Structure:
Width:
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 �} pe: � �
private ublic ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No j�.
jIf so, identify location:
. Propercy Description: Lot size: � • �
. Tax Map#• � 2� 10. Type of structurelfacility: Proposed: �Existing: Q
Parcel#: • � � Type of dwelling:
Townshi : 1,c .� House: � Mobile Home: usiness: ❑
P -
�. Directions to property: State Road #& Road � of business:
lames,�tc. Number of Employees:_
s � umber of bedrooms: �_
�'' Garbage Disposal? Yes ❑ No ��
Basement? Yes ❑ No so, # of basement fixtures:
Number of occupants or
to be served:
1
CLEARLY STAKE ALL CORNERS OF THE P�tOPERTY Ai�ID THE CORrIERS OF ALL
PROPOSED STRUCTURES•
I hereby make application to the Person COunty Health Department for a site evaluation for the on-sitf
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 Permi[ 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 the property to the Health Dept. within 60 DAYS aftec the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfei[ed.
Signc� Owner or Authorized Agenl
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B �453
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.
T� Map # cJ�
Owner/Contractor
Location/Address
Subdivision Name
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T
Parcel #_
Township _
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S.R.# � 1�3�}'
Lot# 3
SEWAGE SYSTEM SPECIFICATIONS
�air Lot Area � ���_
) _� i Mobile Home i/
iness # of Bedrooms�_
CJ� (a:�-�13 �
Permits may be voided if site
Well and Septic �yout by
Size of Tank � � �(��Q�
Size ofPump Tank 6�1�1� �
Nitrification Line '-EC��k3 �
Max Depth Trenches a �-} ��
or intended,use c
Date �� �7/ 9'g Installe��y� �S1�t.Q.; Approved
12eCei 1 l 6 2
Well Permit Paid WELL SYSTEM SPECIFICATIONS
Individual �Semi-Public
Public Replacement
Site Approved
Well Head Approved � � �� 1'�
Grouting Approved •—
Comments:
Date � 0 Installed by
Required Slab �
Air Vent �r �
Required Well Log (�'
Well Tag � �—
�
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-?5-98�T
This report is based in part on ioformation 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
contained in the application. The environmental health sp�cialist 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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AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE:� � — '�( � Il�IPROVEMENT PERMIT #: - ��5�
TAX MAP #: � PARCEL #: ( � _
OWNERIOWNER'S REPRESENTATIVE: �-��
LOCATION/ADDRESS:
SUBDIVISION NAME: � i ���(��� LOT #:
SECTION OR BLOCK:
AUTHORIZATION FOR CONSTRUCTION ISSUED BY:
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 Pernut #��. 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 pernuts.
4. Conditions:
Person Requesting: � ����1 �C,—�
_... __. . ., _.. .. _ . �,. ,, .
� • PERSON COUNTY ENVIRONMEtITAL HEALTH • `�` � `
. . . a�.
• ' • ' •'• WELL LOG ' �'�
• • . . � .
- Date: 8 ' � •
� Owner: _ F�H � SR# ' � -
Location%Directions: T ' r �
] �T �A 1 1i� �� _ . . -.- -
Subdivision N�une:
Drilling Contxactor:
Lot #
WELL CONSTRUCTION � ---
Distance from Nearest Properry Line__l0 Distance from Source of
Pollution l� '
Total Dep.th: 1__ 4d Ft. Yield:��___ GPM Static Water Level�_F�.
Water Bearing Zones: Depth ll� t. Ft F�_ F�.
Casing: Depth: From� to�_Ft. Diamet�r:_ Co`�t.� Inch�s
TYPE: Steel - Galvanized Sceel �
If Steel, does owner app:ove: Yes No
� Weigh[-: � Thic�;ness: �($g Height Above Ground:.�z _ Inches
Drive Shoe: Yes /' No -
Were Problems Encountered in Setting the Casing? Yes No �' �
Ir "yes" give reason:
Grout: Type: Neat Sand/Cement � Concrete •
Annular. Space Width Inches
Water in Annular Space: Yes No
_ .. Method: Pumped � - Pr�ssure � Poured -�.._ . . . , :
Depth: From d to ZC� Ft. � �
Materials Used: No. Bags Portland Cement Weight of .1 bag__lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
�ID Plates: Yes � No � � � � .
�- 4 x 4 slab Yes / No
�
I HEREBY CERTTFY THAT THE ABOVE INFORM�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERS0�1 COui�`I'Y HEALTH DEPARTMENT.
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ignature of Contractor Datc
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