A30 127Amount paid
Receipt ll
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Improvements Permit.(Established/Recorded Lot) _ Reinspection of Existing System (L,oan Closing)
mpxovements Permit (Uncecorded Lot) _ Repair/Replace existing Septic System
_ improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
_ Bacteria
1. Permit requested by: .
�wnec/DiOSDCCt6VC, O W RC[
Address:
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_ Chemical
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Pecmit for New Well
_ Replace Existing Well
_ Petroleum � ._ Pesticide � _ Lead
ome Phone #: 597—�,�� ,�99 �.s9'
usiness Phone #:�����
N/a^me and ad��d�r/e&Jc of current owner.
, / T'rr� 1' %�/l i/�../' �/!�//l/1Gl��
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?
9. Water suppl y pe: --
private . ublic ❑ community ❑ spring ❑ .
Are any wells on adjoining propercy?Yes ❑ No Q.
If so, identify location:
iption: Lot size: �
Tax Map#: �
Parcel#: �
Directions to property: State Road #& Road
Number of occupants or people to be secved:
10. Type of stcucturelfacility: Proposed: DExisting: Q
Type of dwelling:
House: O Mobile Home: usiness: ❑
�pe of business•
Number of Employees:
umber of bedrooms: .�_
Garbage Disposal? Yes ❑ No
Basement? Yes ❑ I�Io 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 COun�y �ealfh Ueparfinent 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 tcue
and represent the maximum facilities to be placed on the propercy. I understand if the site is altered or the
intended use changes, the pecmit shall become invalid. I understand that befoce an Improvements Permit can �
issued, I must present a survey plat of the propercy to the Health Dept. I understand thac in the event I have no�
delivered a survey plat of lhe 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.
Sienc� Owner or Authorized Agent
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B 2560
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE,'I;OCATION 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 # � J� � Parcel # j
Zoning Township �G.
Owner/Contractor E� � __ Date 1 D � 8-- 9c'�
Location/Address
' � � s.R.# �IOC y4
Subdivision Name 1�1'i I( Z) t,J L�.k�.� Lot# /'1
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area��i� G Size of Tank
SFD ✓ Mobile Home ,/ Size of Pump Tank
Business # of Bedrooms�_ Nitrification Line (� �X �, �
Max Depth Trenches �7i� ' �
Permits may be voided if site
Well and Septic Layout by
Comments: ��i��0�
Date
Installed by
or intende� use changed.
�Q Approved by_
ld-�-a� "N''�►�—
Well Permit Paid LvJ W�LL SYSTEM SPECIFICATIONS
Individual �Semi-Public Required Slab �
Public Replacement Air Vent �'
Site Approved Required Well Log �
Well Head Approved -- C_ Well Tag �/
Grouting Approved ►/--��{ 1-a�-95
Comments:
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
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE:� � �� " C �
TAx �r #: 30
=�'ROVEMENT PERMIT #: �o'�S6 d
PARCEL #: �~I
OWNER/OWNER'S REPRESENTATIVE: � �
LOCATION/ADDRESS:
SUBDIVISION NAME:
SECTION OR BLOCK:
LOT #:
TION FOR CONSTRUCTION ISSUED BY:
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 Permit #��. The
construction and installation must also meet alI 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 pernuts.
4. Conditions:
Person Requesting:
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Owner.
Loca[ion/Directions:
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PERSON COUNTY ENVIRONMENTAL HEALTH
5
WELL LOG
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Subdivision Name: ( � �� #
Drilling Contractor: (,�. . y �
Distance from Nearest Properry Line /O Distance from Source of
Pollution_ �C3ej `
Total Dep.th:.__ o?Cx� Ft. Yield:�_ GPM Static,Water Level � Ft.
Water Bearing Zones: Depth /�/�/ Ft. � F� Ft� �t.
Casing: Depth: From�_to�Ft. Diameter._ Co Inches
TYPE: Steel � Galvanized Steel /
If Steel, does owner approve: Y�s No
� Weight: � Thickness: /� HeighrAbove Ground: 6�i Inches
Drive Shoe: Yes ✓ No
Were Problems Encountered in Setting the Casing? Yes No ✓
Zt' "yes" give r�ason:
Grout: Type: Neat Sand/Cement ,/ Coricrete
Annular. Space Width Inches
Water in A.miular Space: Yes No
_ .. Method: Pumped _ - • - � �Pr:ssure � � Poured ✓ -- �. � - • �, � : -
Depth: Fr�m O to_ �. � Ft. � -
Materials Used: No. Bags Portland Cement Weight of 1 bag_lbs.
If mixture (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 1NFORMATION IS CORRECT AND THAT
T�S WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSO�t C�Ui�ITX HEALTH DEPARTMENT. �
.� .ai-22_
Signature of Contractor Datc
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