A30 118Amount paid
Receipt /i
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Improvements PermiG(Fstablished/Recorded L,ot)
pFovements Permit (Un�ecorded Lot)
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Date
Reinspection of Existing System (L,oan Closing)
_ Repair/Replace existing Septic System
Improvements Permi[ (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: .
ress:
Phone #: .S%�—
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,..�99 �.sy'
usiness Phone #: ..�,��,1�
. I�Iame and add�res,S of cucrent owner.
iption: Lot size:
Tax Map#:
Parcel#: �
7. Dimensions or Proposed Structure:
Width•
_ Lead
8. What type (if any, additions, expansions, or
replacement is anticipated to the stcucture or facility
that this sewage disposal system is intended to serve?
9. Water suppl y pe: -
� private . ublic ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No j1.
If so, identify location:
S. Directions to property: State Road #& Road
Number of occupants or people to be served:
I0. Type of structure/facility: Proposed: �Existing: Q
Type of dwelling:
House: � Mobile Home: usiness: O
�ype of business•
Number of Employees:
umber of bedrooms: 3-
Garbage Disposal? Yes ❑ No
Basement? Yes O No so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AI�ID THE CORI�IERS OF ALL
PROPOSED STRUCI'URES.
�I hereby make application to the Pe1sOn COunty Health Uepal'tmenf for a site evaluation for 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 propeccy to the Health 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 forfeited.
Siencc� Owner or Authorized Agent
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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 # A 3� Parcel #_
Zoning Township
Owner/Contractor l�c� ar� � (N1G�,r�l-� �l _
Location/Address �I aS T;
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Date �i-
S.R.#
Subdivision Name ,, �;(� f�,�n,�IC .2 Lot# 5
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area ���J3� Size of Tank ����
SFD � Mobile Home '✓ Size of Pump Tank
Business # of Bedrooms�_ Nitrification Line �''�C �' _
Max Depth Trenches `��} «
Permits may be voided if
Well and Septi�Layout by_
Date
by
�k- �,�f�Iv P��-�,4-titi1
or intended }�se changed.
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Well Permit Paid L�f WELL SYSTEM SPECIFICATIONS
Individual L� Semi-Public Required Slab ,/
Public Rep �ment Air Vent
Site Approved ' Required Well Log
Well Head Approved Well Tag
Grouting Approved , �� � �
Comments:
Date
Installed by
Approved
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 conditio�s 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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' o f Arrson (k�astK osrtt jy that ths �ap. or•.�
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T�t 9 o f ��{� �
- � i ••iPillow Iake Svbddv�is-ion" `. �_
See P.C. !>-22C ""' �
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I � � ProP�rty l{nw iQading {nto th� pond
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"W�liow I.ake Subdivtisio�,,•
See P.C. i1-22C
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BY .tllClA 1� NOBLIIV'
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AUTHORIZATIOI�I FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: `"I — Ql— gS IlVlPROVEMENT PERMIT #: %� � 5 5 Z
TAX MAP #: PARCEL #:
OWNER/OWNER'S REPRESENTATNE: �L( Q�,n � _ I1�Q �--�-� ►�
LOCATION/ADDRESS:
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SUBDIVISION1�IAiv�: �A =) �ll�Z.�� ��� LOT #:
SECTIOI�I OR BLOCK:
FOR COI�ISTRUCTIOI�t ISSUED BY:
AUTHORIZATION CONDITIONS
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1. The Wastewater system construction and installation must meet ail of the conditions of the
attached site plan and specifications as set forth in Improvements Pernzit #�� a55�The
construction and instaltation must also meet aIi applicable rutes 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 Cnctuding structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specifced in the associated improvement
permit and application, may void this authorizacion and associated pernuts.
4. Conditions:
Person Requesting: �—��
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csrti is a mtsta a21 stat�o y
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i ,•iPillow Lake Subd�ivision" •. �,�_
See P.C. 11-22C "`" �
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• I �i I propartv ct,� �aa�ny {sdo t1u por�a.
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"W�llow lake Subdivtis�i,on"
See P.C. 11-22C
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B2: , .�WCIA. R NOBLIN �
Nov-11-98 09:23A Keith Barnette
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