A30 124Amount paid
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Date
Improvements Permit.(EstablishedlRecorded Lot) I_ Reinspection of Existing System (L,oan Closing)
�pxovements Permil (Un�ecorded Lot)
improvements Pecmit (Mobile Home R�
_ Improvements Permit (Addition)
,_ Bacteria
1. Permit requested by:
Address:
�
_ Chemical
.
F
RepaidReplace existing Septic System
. Permit foc New Well
_ Replace Existing Well
_ Petroleum � _ Pesticide � Lead
ome Phone #: S97—i�,?� ,S`99 �.Sy'
usiness Phone #:�,��,,��QO
, N/a„me �d a�es� of cu�t owner.
Tr�� L i r� ii��c ��
7. Dimensions or Proposed Stcucture:
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?
9. Water suppl y pe: -�
private . ublic ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No j�.
If so, identify location:
Description: Lot size: I
Tax Map#:
Parcel#• �
5. Directions to property: State Road #& Road
Number of occupants or people to be secved:
10. Tyge of structurelfacility: Proposed: OExisting: Q
Type of dwelling:
House: ❑ Mobile Home: usiness: ❑
�pe of business•
Number of Employees:
umber of bedrooms: ,�,_
Garbage Disposal? Yes ❑ No
Basement? Yes ❑ No so, # of basement fix[ures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY A1�ID THE CORrIERS OF ALL
PROPOSED STRUCTiJRES.
�I hereby make application to the Person COunty �ealth Uepartmen� for a site evaluation for the on-site
sewage disposal system for the above described properey. I agree that the contents of this application are true
and represent the maximum facilities to be placed on the propecty. 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 C
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
th@site by the Health Dept., this application shall become void and all fees paid forfeited.
Sienc3 Owner or Authocized Agent
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B 2807
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 # .�c � �
Zoning
Owner/Contractor �E 1-�
Location/Address
S.R.#
Subdivision Name ` 1��,J L�L-� _ Lot# �
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area �,�b � C� Size of Tank ��b�c�QQ � Ir'� ���
SFD '�/ Mobile Home ✓� Size of Pump Tank
Business # of Bedrooms� Nitrification Line y(�'x3'
Max Depth Trenches 'o? N ' `
Permits may be voided if site is
Well and Septic out by
Comments: �—�<'�SX�
Installed
��c��.o�y� ��
or intende use changed.
� o�- r ��.�,r-� . C�.-s .
Approved
ell Permit Paid Lfi'?� WELL SYSTEM SPECIFICATIONS
3ividual '✓ Semi-Public Required Slab
�blic Replacement Air Vent
te Approved Required Well Log �
ell Head Approved Well Tag ✓
-outing Approved � — °� E�
Comments:
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 conditions on the property or for statements in this
� report that may have resulted from false or misleading statements provided to
E-' 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
�
� � AUTHORLZATION FOR WASTEWATER SYSTEM CONSTRUCTION
� (Void sixty (60) months from date of issuance)
DATE: ���,5-99 Il�iPROVEMENT PERMIT #: �-a�b']
TAX MAP #: �� PARCEL #: � o��-i
OVYNER/OWNER'S REPRESENTATIVE: ��l !
LOCATION/ADDRESS:
SUBDIVISION NAME: �� `� � l� L� l�t-�-�- LOT #:
SEGTION OR BLOCK:
FOR CONSTRUCTION ISSL7ED BY:
AUTHORIZATION CONDITIONS
1. The Wastewater system construction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Pernut #��7 . The
constn�ction 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
pernut and application, may void this authorization and associated pernuts.
4. Conditions:
Person Requesting:
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— ` Old
�'� -' - -� - _ �.�rtb Line --
1 `ss4�>9 �21",E - �- _ ,_ ` _ ---
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Date: 3 ' a' �� � �
Owner. ��
Location/Directions:
Subdivision Name:
Drilling Contractor:
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Y S / T �-- � .C�n�
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SR#
Lot # � �
. WELL CONSTRUC'I'I�'N
Discance from Nearest Properry Line / U Distance from Source of
Pollution � (,�,0 `
Total Dep.th: f�0 Ft. Yield: �(U GPM Static Water Level �.� Ft.
Water Bearing Zones: D�epth /�v Ft. /3v Fc. � F� ��,
Casing: Depth: From O to �£��_Ft. Diameter._ Co Inches
TYPE: Steel - Galvanized Steel i--�---
If Steel, does owner approve: Yes No
� Weight: � Thickness: /� Height�Above Ground: 6�% Inches
Drive Shoe: Yes ✓ No
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" give r�:ason:
Grout: Type: Neat SandJCement ,/ Coricrete
Annular. Space Width Inches
Water in Aruiular Space: Yes No.
_ .. Method: Pumped . . . .Pr:ssure . - Poured_,/ � �- -. . . . •, - : .
Depth: From O to_ �� Ft. � � -
Materials Used: No. Bags Portland Cement Weight of .1 bag_,_lbs.
If mixtuie (sand, gravel; cuttings) - Ratio: to
�ID Plates: Yes ✓ No � � � � � -
�� 4 x 4 slab Ye:s�—No �
:
i
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON COLi�'I'Y HEALTH DEPARTMENT. �
✓ �-j��9�--
�Signaturc of Contractor Dat�