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Permit. (Fstablished/Recorded Lot) ._ Reinspection of Existing System (Loan
ImpFovements Permit (Unrecorded Lot)
_ RepaidReptace existing Septic System
_ Improvements Permit (Mobile Home Replace) _ Pecmit for New Well
Improvements Permi t ( A d di t i o n) _ Re place Existing Well
1. permit requested by: �o.va�.d 1-t ''�'��''G' ({p''�
owner/prospective owner/agent: i�� ` �( � ��*'�-`��-°✓
Address: 3'7 ( 1�..�.u;- - P''(,—_
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ome Phone #:
usiness Phone #: 549 --.t_4� oo �'�1-�
Name and address of,cucrent owner:
7. Dimensions or Proposed Structure:
Width: ��
. Propercy Description: Lot size: (�`{'� FiZVQ-
. Tax Map#: �i4 � 3o I-� 1`0�
Parcel#: 1 �--j ��,1's+--
T.ratrnciiin• �z.. c1. _� �✓ � �
. Directions to property: State Road #& R�o,P��
iames,�tc. ��� ��� "�° �
5 v�(: te5 -- Qv��c7ft( �� a n1 `{�t� le�'f"`�j •J-st'
cAn t T 'rJ � � � �L^
Number of occupants or people to be served:
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 su ly ty pe:
private public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No p:
If so, identify location:
10. Type of structurelfacility: Proposed: �Existing: Q
Type of dwelling: ��
House: � Mobile Home: Ld'Business: ❑
,Type of business:
Number of Employees:
Number of bedrooms: �_
Garbage Disposal? Yes �❑, �o �
Basement? Yes ❑ Nol�d'If so, # of basement fixtures:
CLEARLY STAKE ALL CORI�IERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTIJRES•
I hereby make application to the PeI'SOn COunty. Health Depal'tment for a site evaaua;i� tion ahe �e ite
sewage disposal system for the above described property. I agree that the contents of this pp
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 be
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 all fees paid forfeited.
Signca Owner or Authorized Agent
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT
B 2463
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 # � �7
Zoning Township �.,�,
Owner/Contractor
Location/Address
Subdivision Name
- Date " 9 -�-
S.R.#
Lot# � 7
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area� .�-(0,�� Size of Tank ����
SFD L/ ' Mobile Home,�- Size of Pump Tank
Business # of Bedrooms�_ Nitrification Line L.�(� ` Xa'
Max Depth Trenches � '� � �
Permits may be voided if site
Well and Sept' Layout by
Comments: �,�� Q
Date
Installed by
�- A -�I - �
�CM �o {'v� ���-rV��
or intepded use ghan��_
Approved by
Well Permit Paid L1�i WELL SYSTEM SPECIFICATIONS
Individual l� Semi-Public Required Slab ✓
Public Re lacement Air Vent
Site Approved � Required Well Lo�
Well Head Approved Well Tag �/
Grouting Approved � g I D -� �- �f � � � � �/
Comments:
by
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 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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AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: --'7 -'� c� IMPROVEMENT PERMIT #: y%
TAX MAP #: O'r : PARCEL #: I o'�
OWNER/OWNER'S REPRESENTATIVE: K� ni b('if ��,/ lT �f��
LOCATION/ADDRESS: c
SUBDIVISION I�IAME: \ � � `l �'V �, � _ LOT #: I L
SECTION OR BLOCK:
AUTHORIZA,��@i��OR CONSTRUCTIOI�I ISSUED
AUTHORIZATION COI�IDITIONS
1. The Wastewater system construction and installation must meet ail of the conditions of the
attached site plan and specifrcations as set forth in Improvements Pernut #��y� The
, construction and instaliation must also meet aII applicable rules and laws.
2. No poction of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any a[terations in site or soil condifions (including structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and appiication, may void this authorization and associated permits.
4. Conditions:
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Person Requesttng: _
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Owner. �
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Subdivision Nafne:
Drilling Contractor:
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PERSON COUNTY ENVIRONMENTAL HEALTH
S�'
WELL LOG
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SR# _ ►..
Lot #
. WELL CONSTRUCTId'N --
Distance from Nearest Property Line /C1 Distance from Source of
Pollution /(x� `
Total Dep.th:_/av Ft. Yield: c5'v GPM Static Water Level S' Ft.
Water Bearing Zones: D�epth �Ft. ��_Ft� � F� F�.
Casing: Depth: From U to�_Ft. Diameter: Co Inches
TYPE: Steel - Galvanized Steel _�
If Steel, does owner approve: Y�s No
� Weight: � Thickness: !� HeighrAbove Ground: � ti Inches
Drive Shoe: Yes ✓ No -
Were Problems Encountered in Setting the Casing? Yes No ,� �
If "yes" give r�ason:
Grout: Type: Neat Sand/Cement ,/ Concre[e �
Annular. Space Width Inches
Water in Annular 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 Yes�—No �
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I HEREBY CERTIFY THAT THE ABOVE INFORM�ITION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH gy�THE PERSO�I C�Ui�'I'y HEALTH DEPARTMENT. �
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S gnature of Contractor Da��
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