A30 120Amount paid
'Receipt /i
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Date
Improvements Permit.(Established/Recorded Lot) �_ Reinspection of Existing System (Loan Closing)
�[�ovements Permit (Un�ecorded Lot)
improvements Pennit (Mobile Home Replace)
Improvements Permit (Addition)
_ Bacteria
1. Permit requested by:
_ Chemical
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Repair/Replace existing Septic System
_ Permit for New Well
_ Replace Existing Well
_ Petroleum � _ Pesticide � _ Lead
:ome Phone #: .sf7—�',?� ,S'�99 �.s9'
usiness Phone #: ��,� ;1�0
, I�Iame and add�es� of cucrent owner.�_
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 secve?
. Property Description: Lot size: �
Tax Map#:
Parcel#: �
. Directions to property: State Road #& Road
. Number of occupants or people to be served:
9. Water suppl } pe: - �
private . ublic ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No [�.
If so, identify location:
I0. Type of stcucturelfacility: Proposed: �Existing: Q
Type of dwelling:
House: � Mobile Home: usiness: ❑
��pe of business•
Number of Employees:
umber of bedrooms: �_,
Garbage Disposal? Yes ❑ No
Basement? Yes ❑ I10 so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AI�ID THE CORNERS OF ALL
PROPOSED STRUC�'URES.
�I hereby make application to the Person COuniy �ealth Uepartment for a site evaluation 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 permit shall become invalid. I understand that before an Improvements Permit can E
issued, I must present a survey plat of the property 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 after the date of the evaluation of
the site by the Health Dept., this application shall become void and ali fees paid forfeited.
Sienc� Owner or Authorized AQent
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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 # f� ?J � Parcel # ( 2 �
Zoning Township � �,ts�u_,, �-T'�
Owner/Contractor C�r� � S 1 �J � 11 � a r►tiS ate g-2(o � 9�
Location/Address �-1 qS �
`� ' S.R.#
Subdivision Name � �- Lot# `-7
SEWAGE SYSTEM SPECIFICATIONS
Lot Area
Size of Tank
) �- Mobile Home V Size of Pump Tank U N _
iness # of Bedrooms� Nitrification Line �O �X� �
Max Depth Trenches ] �' '�
Permits may be voided if
Well and Septic Layout by_
Comments: ��-�. � �
Date
LT�K=•25
altered or intended use changed.
Approved
ell Permit Paid WELL SYSTEM SPECIFICATIONS
�"Semi-Public Required Slab �/
�blic Replacement Air Vent
te Approved �� Required Well Log
ell Head Approved ✓ Well Tag
�Grouting Approved �B� 9-?3
Comments: I(� ��U v��. •
.
Date l� 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 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:\amiprolpermit.sam O1/95 rev.l.l
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: ��Z�-4 � IMPROVEMENT PERMIT #: 2
TAX MAP #: �� PARCEL #: I ZC� �
OWNER/OWNER'SREPRESENTATIVE: ����(`"l�� �`���
LOCATION/ADDRESS:
SUBDIVISION NAME: � � u (�,( ) L� � � � LOT #: �_ .
SECTION OR BLOCK:
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 Petmit #,�� 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 permits.
4. Conditions: `
Person Requesting: �r 1 Q;� ��S
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PERSON COUNTY ENVIROPIMEtdTAL HEALTH
WELL LOG
Date: �'Q �'
Owner: �
L,ocation/Directions:
Subdivision Name: .___(�
Drilling Contractor: I
SR#
Lot # -
WELL CONSTRUC"I'ION V -
Distance from Nearest Properry Line_ le� Distance from Source of
Pollution It�o '
i otal De�th:_!oZ c3 _ Ft. Yi�.ld:�5�_ GPM Static 1�'ater Level�_ �=�.
Wa[er Bearing ;Lones: Depth .�� rt._ �� F��Ft.__ Ft,
Casing: Dept}i: From G� to� �( Ft. Diametcr: � l�jn�}��;
TYPE: Steel - G�Ivanized Sceel �—'
If Steel, does owner app:ove: Yes No
Weight: Thickness;/ �- Y Height�Above Ground: �� Inches
Drive Shoe: Yes �'" No
Were Problems Encountered in Setting the Casing? Yes No �
Zf "yes" give reason:
Grout: Type: Neat Sand/Cement �' Concre[e
Annular Space Width _Inches
Water in Annular Space: Yes No
_ . Method: . Pumped . . - Pr�ssure . � Poured� . _ . . . .. : .
Depth: From_ 1' to � � . .
Materials Used: No. Bags Portland Cemenc Weight of .1 ba� lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes �' No � � �� � .
� 4 x 4 slab Yes � No L
I HEREBY CERTIFY THAT THE ABOVE INFORM�TION IS CORRECT AND THAT
THiS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSO�t C�Li�"I'Y HEALTH DEPARTMENT.
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