A30 117�
Amount paid
�eceipt li
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11767
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Date
Improvements Permit. (EstablishedlRecorded L,ot) �_ Reinspection of Existing System (Loan Closing)
improvements Pecmit (Un�ecorded Got)
Improvements Permit (Mobile Home Replace)
Impcovements Permit (Addition)
_Bacteria � _Chemical
Permit requested by: .
ner/prospect ve ow er/•
dress: •� a
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ime Phone #: S%%_
RepaidReplace existing Septic System
. Permit for New Well
_ Replace Existing Well
_ Petroleum � ._ Pesticide � Lead
7. Dimensions or Proposed Structure:
Width:
Depth:
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?
,.S`%9 �9.sy' .
usiness Phone #:��9 ��QO_
. I�Iame and add�es�S of current owner.
Description: Lot size:
Tax Map#: �
Parcel#: � I -7 G�
_ .. �. .. � ��
Directions to propercy: State Road #& Road
I�Iumber of occu ants or ple to be served•
9. Watersuppl ype: - -
private ublic ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No [�.
If so, identify location:
I0. Type of structurelfacility: Proposed:.�Existing: Q
Type of dwelling:
House: Cl Mobile Home: usiness: ❑
of business
Number of Emplayees:
umber of bedrooms: 3_
Garbage Disposal? Yes ❑ No -�
Basement? Yes ❑ I�Io so, # of basement fixtures:
��• P �° • � -
CLEARLY STAKE ALL CORI�IERS OF THE PROPERTY AI�ID THE CORI�IERS OF ALL
PROPOSED STRUCTURES.
�I hereby make application to the PetsOtt COunty �e3lth Depat'tment for a site evaivation for the on-site
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 pecmit shall become invalid. I understand that before an Improvements Permit can �
issued, I must present a sucvey plat of the property to the Health Dept. I undecs[and that in the event I have no�
deliveced a survey plat of the property eo the Health Dept. within 60 DAYS aftec the da[e of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
SiQnc� Owner or Authorized Agent
.. •• B 2452
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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 # � J� Parcel # ` �
Zoning Township ��, ('�.
Owner/Contractor
Location/�dtess
�
Subdivision Name �� ;�( �� 1�Q� e— Lot#
�o
S.R.# l t �2
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area � �� I/}-C— Size of Tank
SFD �� Mobile Home L� Size of Pump Tank
Business # of Bedrooms�_ Nitrification Line �-f� �y3 �
Max Depth Trenches � � � �
Permits may be voided if site is
Well and SepticrL�yout by
Installed
or intended
Well Permit PaidT� WELL SYSTEM SPECIFICATIONS
Individual �/S�emi-Public Required Slab _
Public Re ement Air Vent
Site Approved Required Well Log
Well Head Approved Well Tag
Grouting Approved �_q - y- 9� �-�o$� b� l�
Comments:
Date �/U -
[� �L�R1Z�J'.'� � � � . - �
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
contained in the application. The environmental health specialist is also not
responsible for concealed conditioos 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:\amiprolpermit.sam O1/95 rev.l.l
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AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: � � � �� IlVIPROVEMENT PERNIIT #: ��j
TAX MAP #: PARCEL #: �
OWNER/OWNER'S REPRESENTATIVE: �c=�'�� /7
LOCATION/ADDRESS:
SUBDIVISION NAME:
SECTION OR BLOCK:
�ll
AUTHORIZATION FOR CONSTRUCTION
:
AUTHORIZATION CONDITIONS
LOT #:
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1. The Wastewater system construction and installation must meet all of the onditions of the
attached site plan and specifications as set forth in Improvements Pernut #�%�The
construction and installation must also meet alI 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 permits.
4. Conditions:
Person Requesting:
; :- .
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PERSON COUNTY ENVIR021MEHTAL HEALTH
WELL LOG
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Date: $ � ' � '
Owner. �� I-� � SR# ' � � .
Location/Directions: _�1�� T/� o�.c. c �ac,�u,c�s �ta�c nu� ►-�u �..�.{ � �
� -------..�.«.` � �
L�T o�l �i -,s -�N-r � ,
Subdivision N�une:
Drilling_Contractor:
Lot #
WELL CONSTRUCI'ION ' ----
Distance from Nearest Properry Line__� Distance from Source of
Pollution �� '
Total Depth:_ (Zp Ft. Yicic�:_ ZS_______ GPM Static Water Level__��,�_____j=�.
Water Bearing Zones: Depth�o"z�?=t.g(��Ft� (( �,.Ft�_ �t.
Casing: Depth: From o to��__Ft. DiaJneter: lnches
TYPE: Steel � Galvanized Steel /
If Steel, does owner app:ove: Yes No
Weight: Thic�;ness: . t$8 ,Height Above Ground: I�1 Inches
Drive Shoe: Yes / No
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" gi�e reason:
Grout: Type: Neat Sand/Cement �' Coricrete
Annular. Space Width Inches
Water in Annular Space: Yes No
_ . Method: Pumped � - Pr�ssure � � Poureti��_ � � °. . .
Depth: From o :o ZO Ft. . .
Materials Used: No. Bags Portland Cement 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 INFORM�ITION IS CORRECT AND TH AT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH $y�THE PERSON C�ui�ITY HEALTH DEPARTMENT.
ignaturc of Contractor D1tc