A30 121Amount paid
�Receipt l/
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Improvements Permit.(Established/Recorded Lot) �_ Reinspection of Existing System (Loan
�pFovements Permit (Unrecorded LoQ
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
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�� _Bacteria _Chemical
1. Permit requested by: .
owner/prosp/e�ct ve ow e/r/� gent:���
d ri rl rP cc• _( /70,./. /5 //�i�l S f%%%i„
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Repair/Replace existing Septic System
_ PeRnit for New Well
_ Replace Existing Well
_ Petroleum
.ome Phone #: 597—�%',7� ,�99 �y.Sy'
usiness Phone #:�,��,,�� 4
. Name and add�es�S of cucrent owner.�_
3. Propercy Description: Lot size:
4. Tax Map#: �
Parcel#: �
Township:
5. Directions to propercy: State Road #& Road
. I�Iumber of occupants or people to be served:
_ Pesticide � _ Lead
7. Dimensions or Proposed Structure:
Width:
Depth:
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure oc 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 [�.
If so, identify location:
I0. Type of structurelfacility: Proposed: �Existing: Q
Type of dwelling:
House: ❑ Mobile Home: usiness: ❑
�ype of business:
Number of Employees:
� umber of bedrooms: .�._
Garbage Disposal? Yes ❑ No
Basement? Yes ❑ No so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY Ai�ID THE CORI�IERS OF ALL
PROPOSED STRUCZ'URES.
I hereby make application to the PersOn COunty T3ealth 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 E
issued, I must present a survey plat of the propercy to the Health Dept. I understand that in the event I have no�
delivered a survey plat of the property co the Health Dept. within 60 DAYS after the date of the evaluation of
thesite by the Health Dept., this applicatian shall become void and all fees paid forfeited.
Siencci Owner or Authorized Agent
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B 2567
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 # � �� Parcel # �
Zoning Township _
Owner/Contractor��
o ation/Address E'j
Subdivisi n Name ( �`� ;
Lot#
Date
��
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area� , D� �� Size of Tank (�(���,0.Q
SFD �/ � Mobile Home ✓ Size of Pump Tank
Business # of Bedrooms�_ Nitrification Line OZ� �X3 '
Max Depth Trenches p—t � � �
� yC� ��G [�A-j�ns
Permits may be voided if ''s aitered or i� te ed ise changed.
Well and Septic �ayout by „�, l/�Qi� , _ , _ �
Comments:
- -- - - r - - - -- �- -- - -- -- a- -- - - - _ _ . _ . .
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:\amipro\permit.sam O1/95 rev.l.l
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AUTHORTZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date oE' issuance)
DATE: �(� — I�—�I g II��PROVEIV�NT PERMIT #: �u ' b
TAX MAP #: � Z� PARCEL #: � a' �
OWNER/OWNER'S REPRESENTATIVE: ��
LOCATION/ADDRESS:
SUBDIVISIOIIIIAME:
SECTION ORBLOCK:-
LOT #:
FOR COI�ISTRUCTIOI�I
:
AUTHORIZATION COIIDITIONS
1. The Wastewater system construction and instaIlation must meet all of the conditions of the
attached site pIan and spec'tfrcations as set forth in Improvements Pernut #��% The
construction and instaltation must also meet ali applicabie ruies and laws.
2. No portion of the Wastewater system shall be covered or placed into use untii inspected and
approved by the Person County Health Department.
3. Any a[terations in site or soil conditions (inciuding structure Iocations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and appiication, may void this authoriz,ation and associated pecmits.
4. Conditions:
Person Requesting:
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See P.C. 11-22C
Date: '
Owner. E�
Locatiori/Directions:
Subdivision Name:
Drilling Con�ractor:
. _ . . ._....._.._...- ,
PERSOH COUNTY ENVIRONMENTAL HEALTH
WELL LOG
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llistance from Nearest Properry Line 1 p Distance from Source of
Pollution .I Cx'� `
Total Dep.th:� I�O Ft. Yield: �b GPM Static Water Level 7.. Ft.
Water Bearing Zones: D�epth 1S t.- q� t� � Ft ��,
Casing: Depth: From O to�_Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel �
If Steel, does owner approve: Yes No
� Weight�: � Thickness: 1 F� Height Above Ground: ��� Inches
Drive Shoe: Yes ✓ No
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" gire r�ason:
Grout: Type: I�teat Sand/Cement �/ Coricrete
Annular. Space Width Inches
Water in ATuiular Space: Yes No.
_ .. Method: Pumped . . . �Pr:ssure � - Pourzd �/ •�- �. - � • �. - .
Depth: From O to �, � Ft. . . -
Materials Used: No. Bags Portland Cement Weight of .1 bag__lbs.
If mixtute (sand, graveI; cuttin�s) - Ratio: to
�ID Plates: Yes ✓ No a ' � �- � .
�� 4 x 4 slab Yes—�—No �
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I HEREBY CERTIFY THAT THE ABOVE INFORM�ITION IS CORRECT AND THAT
T�S WELL WAS CONSTRUCTED 1N ACCORDANCE WITH REGULATIONS SET
FORZ'H gy.THE PERSO�I C�Li�ITY HEALTH DEPARTMENT. �
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Signature oE Contractor ate
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