A30 119Amount paid
Re'ceipt li
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Improvements Permit.(EstablishedlRccorded L,ot)
ments Permit (Uncecvrded I.oQ
Improvements Permi[ (Mobile Home Replace)
Improvements Permit (Addition)
_, Bacteria
1. Permit requested by:
�wner/�rospectkve, owa�
me Phone #:
_ Chemical
�
usiness Phone #:�,�9 ,�� O
Name and
��.�� , i���
Pd a-�
�.��.�-
r.n» ecvvrrr<c I��g
%/-9� ,
Date
of Existing System (Loan
_ RepaidReplace existing Septic System
Permit for New Well
_ Replace Existing Well
_ Petroleum � ._ Pesticide � Lead
,S'99 �.sy'
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?
of cucrent owner. 9. Water suppl -ype: --
-�� �'�,v_ , �� private . ublic ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No (�.
If so, identify location:
3. Property Description: Lot size:
4. Tax Map#: �. I0. Type of structure�facility: Proposed: OExisting: Q
Parcel#: � Type of dwelling:
Township: � House: � Mobile Home: usiness: ❑
5. Directions to property: State Road #& Road � of business:
ames,gtc. Number of Employees:
S , umber of bedrooms: ..�_
Garbage Disposal? Yes ❑ No
Basement? Yes ❑ No so, # of basement fixtures:
I�Iumber of occupants or people to be served:
CLEARLY STAKE ALL CORNERS OF TT3E PROPERTY AND THE CORI�IERS OF ALL
PROPOSED STRUC�'URES.
�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. 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 Health Dept. I understand that in the event I have no�
delivered a survey plat of the property eo the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
i
c�i
z'a �
z Siencci Owner or Aulhorized AQent
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, 26��
� . � PERSON COUNTY HE.�4LTH DEPARTMENT
' - �VELL AND SEWAGE SITE, LOCATION IMI'ROVEMENT 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 # ��� Parcel #
Zoning Township r
Owner/Contractor jj/� ; L�� o�- �,.y� �. C(C�;_b� � n e Date �-�{- 9
Location/Address �-(-4ST/� l,� : 11 n�l � Lst. (C�. 4�J� )�� cZ�
Subdivision Name \ i � 1 `.
S.R.#
Lot#� �
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area �'� y� C
SFD ► � Mobile Home 's
Business # of Bedrooms�
Size of Tank �1��,0�-�
Size of Pump Tank _
Nitrification Line . (S[j '1C3'
Max Depth Trenches �6 «
� �C��l� �1C. ��^�-Uir��
a
v Permits may be voided if 'te is altered or inte ded use changed.
� Well and Septic Layout b
a Comments: �
' ` � 1
i Dat �- � �- q 9 Installed by Tom m� e. C� ( I� e Approved by
Well Permit Paid �' .. WELI, SYSTEM SPECIFICATIONS
Individual � Semi-Public Required Slab _
Public Replacement Air Vent
Site Approved � Required Well Log �
Well Head Approved Well Tag (�
Grouting Approved : , j = ���j � (� ; �, �
Comments:
P/L
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D e -- Installed by_'1� ���; ��� _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
contained in the application. The environmental health specialist is also not
responsible for concealed ca:.ditions 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
0
�. AUTHORIZATION FOR WAS`I'EWATER SYSTEM CONSTRUCTION
_ • • (Void sixty (60) months from date of issuance)
� -DATE: �—�' % q IlViPROVEMENT PERMIT #: �6`7
TAX MAP #: PARCEL #:
OWNER/OWNER'S REPRESENTATIVE: ���2-���1`0.� CIQ. Y,Y�r�_
LOCATION/ADDRESS:
SUBDIVISION NAME: � � , � � O lA� �-Q-��- � LOT #:
SECTION OR BLOCK:
AUTHORLZATION FOR CONSTRUCTION ISSUED BY:
.TION CONDITIONS
1. The Wastewater system construction and installation must meet alI of the conditions of the
attached site plan and specifications as set forth in Improvements Pecmit #�����i -. 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 (inciuding 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 ENVIRONMENTAL HEALTH
� •• � WELL LOG '
Date:�
Owner.
Locatio
._.. : . •..- `� �5� �
a�
. — � '.
.�� '
Subdivision I�tame:
Drilling Contractor:
�..ot �
Distance from Nearest Property Line �c.� Distance from Source of
Pollution !OU '
Total D.ep.th:�_ Ft. Yield: /p GPM Static Water Level c�,S�' Ft.
Water Bearing Zones: D�epth �Ft. /�U � Ft� � F�, F�
Casing: Depth: From�_to�_Ft. Diameter:_ (� Inches
TYPE: S[eel - Galvanized Steel i
If Steel, does owner approve: Y�s No
� Weight: � Thickness: /FS� Height�Above Ground: < t� Inches
I?rive Shoe: Yes ✓ No -
Were Problems Encountered in Setting the Casing? Yes No r�
If "yes" give r�ason:
Grout: Type: Neat Sand/Cement � Concrete
Annular. Space Width Inches
Water in Annular Space: Yes No.
_ . Method: Pumped - � Pressure � � Poured,���_ . . . •, - ..
Depth: From O to �. � Ft. � �
Materials Used: No. Bags Portland Cement Weight of 1 ba�_lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
�ID Plates: Yes� No � ' • � ' -
'� 4 x 4 slab Yes No �
. .
Z HEREBY CERTIFY THAT THE ABOVE 1NFORMr�'IZON IS CORRECT AND THAT
T�S WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY-THE PERSO�t COUi�iTY HEALTH DEPARTMENT. �
.� -�7
�Signaturc of Contractor D1tc
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