A30 128Amount paid
Receipt il
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Date
Improvements Permit.(Established/Recorded Lot) I_ Reinspection of Existing System (Loan Closing)
�pxovements Permit (Un�ecorded LoQ
Improvements Permit (Mobile Home Replace)
Tmprovements Permit (Addition)
_ Bacteria
1. Permit requested by:
owner/prospec yve� owy��
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_ Chemical
F
Repair/Replace existing Septic Sys[em
_ Permit for New Well
_ Replace Existing Well
_ Petroleum � _ Pesticide � Lead
Home Phone #: S�/7—�,�� ,.5�99 �.Sy'
Business Phone #:���' 1�
2. �me �d a�es� of cu�t owner.
Trr� L .� ��������
7. Dimensions or Proposed Structure:
W idth:
Depth:
8. What type (if any, additions, expansions, or
replacement is anticipated to t�e structure or facility
that this sewage disposal system is intended to serve?
9. Watersuppl ype: - -
private ublic ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No Q.
,If so, identify location:
, Property Description: Lot size:
, Tax Map#: � 10. Type of structurelfacility: Proposed: �Existing: Q
Parcel#: � Type of dwelling:
Township: � _ House: � Mobile Home: usiness: ❑
. Directions to property: State Road #& Road �� of business:
iames,gtc. Number of Employees:
� � umber of bedrooms: ,�_
� � Garbage Disposal? Yes ❑ No -
Basemeat? Yes ❑ No so, # of basement fixtures:
. Number of occupants or
le to be served: �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AHD THE CORNERS OF ALL
PROPOSED STRUCTIJRES.
�I hereby make application to the Person County T3ealth Uepartment for a site evaluation for the on-sitE
sewage disposal system for the above described propercy. 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 �
issued, I must present a survey plat of the property to the Healch Dept. I understand that in the event I have not
delivered a survey plat of lhe property to the Health Dept. within 60 DAYS after the date of the evaluation of
thesite by the Health Dept., this application shall become void and all fees paid forfeited.
Sienc� Owner or Authorized AQent
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2661
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 # l�i" � Parcel # Z�
Zoning Township u�. � f
Owner/Contractor n f1v f` �1' ;(1 Date - -
Location/Address QS nrl �-2� _: u..5-E- �OQ-�-�- Vac.c�1A`S `� C3�p��
Subdivision Name
Lot# %-r'j'
SEWAGE SYSTEM SPECIFICATIONS
# YQS
air Lot Area '� , 34� Size of Tank ���
) �,� Mobile Home v Size of Pump Tank
iness # of Bedrooms 3 Nitrification Line i�OZ�'X� �
Max Depth Trenches a5!'�
Permits may be voided if site is
Well and Septic ayout by
Comments: n ��
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ell Permit Paid
intended use
Approved by.
I-8-4'g '
WELL SYSTEM SPECIFICATIONS
Individual_�Semi-Public Required Slab _�
Public Replacement Air Vent
Site Approved Required Well Lo '
Well Head Approve Well T g
Grouting Approved � o`�
Comments: (.. P L � �
Date �$�R Installed by Approved by
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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
�G �
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: I �I % — �' � IlVIPROVEMENT PERNIIT #: ��o I
TAX MAP #: � PARCEL #: I 2�
OWNER/OWNER�S REPRESENTATIVE: �GL,n n� �J ; r�
LOCATION/ADDRESS:
�
.�
SUBDIVISION NAME: \�� � t�� �� l�.l�-� LOT #: I�
SECTION OR BLOCK:
AUTHORIZATION FOR CO��TION ISSUED BY: ��^ ---�`�
.TION 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 #_r�. 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 aIterations in site or soil conditions (including structure Iocations) 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: �
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Person Requesting:
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PERSOR COUNTY ENVIitONMENTAL HEALTH
' Date: - - '
� � O�wner. � � �'
Location/Directions:
�uou�vIsion i�ame:
Drilling Contractor:
WELL LOG
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SR#
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Distance from Nearest Property Line /U D'utance from Source of
Pollution_ �dd `
Total Dep.th:� Ft. Yield: �d GPM Static Water Level ` Ft.
Water Bearing Zones: Depth�_Ft. �ad� F� � Ft�_��,
Casing: Depch: From d to � Ft. Diameter:_� Inches
TYPE: S teel - �s�anized S teel i
If Steel, does owner approve: Y�s No
� Weight�: � Thickness: /�S HeighrAbove Ground: 6�i Inches
Drive Shoe: Yes ✓ No
ViTere Problems Encountered in Setting the Casing? Yes No �
If "yes" gi� e r�ason:
Grout: Type: Neat Sand/Cement ✓ Coricrete
Annular. Space Width Inches
Water in Annular Space: Yes No
_ .. Method: Pumped . .- - �Pr�ssure . . Pourzri ✓ ��� �- . . . •, _
Depth: From O to �. � Ft. . .
Matenals Used: No. Bags Portland Cement Weight of .1 bag lbs.
If mixture (sand, gravel; cuttin�s) - Ratio: to
-ID Plates: Yes ✓ No � � � •-' .
"� 4 x 4 slab Yes—�—No �
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:
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I HEREBY CERTIFY THAT THE ABOVE INFORM�'IZON IS CORRECT AND THAT
T�S WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSO�t C�Ui1'I'y HEALTH DEPARTMENT.
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�Signaturc of Contractor D1tc
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