A30 130. . . . . .'.�;. . �
Amaunt paid � ... �J'�
' Receipt p
. l� '� . q ��
Date
I. Permit requested by: .. �. 7: Dimension� r Proposed Stn�ctu�e: .
owner/prospective owncr/agcnt:��Arn� E as :` Width:
. 56 � 60
Address: • ��' � � Depth:
2,322, •. ✓o � 8. Whal typc (if any, additions, expansions, or
� � replacement is anticipaled to the slcucture or facility
� .
w that �h�< <Pwave disposal.system �s"intended to serve?
U Home Phonc #�: q I q- 2'ZO � yZ� � . -� -�
� usiness Phone �: q! q -7.3 Z "' 6q6 $ � � -
n.. . : ,
�` 2. Name and address of current owner. � 9: Vilater su ply t}•pe:�
. Q,� � L �- � privale i�- public � community ❑ spring ❑
'`� ,,;, A�e any wells on adjoining property?Yes O No [�
o � �
� . � o , � If:so, �dcntify.location:
� 3. Property Dcscription: Lot size: �•00 -1-` l•.� $�
� n- 3 d � ' 10. Type of structurelfacility: Proposed: xisting: Q
t`� Taz lviap# %�' � . � .
• Parccl�:': � . � ': TYpe of dwdling: ,��
G ' House: ❑ Mobile Home: Ly'gusiness: ❑
Townshi ✓ �
� p Y TYP�,of business: �
oa. 5. Directions.to propcny:� State Road #& Road `� Nuc�ber.of Employees:_ - . .
ar�:es, tc.
� � � : r ,� : � � S�� . Numbet of bedrooms: _— :
�. , . � . :• . � arbage:Disposal? Yes �O� o 0
E-. . �•. �. ��- s �:� Basement?.Yes�, NoIJ"If so, # of basement fixtures;
� ,�, � o J`� . L rd M . -c ' ..
.� 6.. I�Iumber of occupants or people to be secvcd: � ' � �
:: CLEAR�'S� STAKE ALL_CORNSRS O��THE P�tOPERTX AND Ti�E CORI�IERS OF ALL
.T�ROPOSED STRUC�'U�tES• � -
I hcreby ma�Ce appltcaUo� to the PerSOri .COl1I1�y Health Uepartment for a site evaluation for the on-sicr
scw�ge disposal.syslem for the above descri b e d pcope rty. I agre e t h a t t h e c o n t c n t s o f t h i s a p p l i c a t i o n are tcue
an d:represent t he.;ma,�cimum faci li ti c s� t o. b e: p l a c e d; o n t h� p r o p e c t y.• � I understand if the sice is altered or the
intefided use�changes; thc'pecmit shall become inval�d 's:I uhdcr5tand that before an Improvements Permit can l•
o,issucd, I'must _ptesenE a survey plat�of the pcopeciy. to the.�Iea11t► Depc. I understand that in the event I have nc�
'-' dc livere d` a survcy.p l',a� o f t h c piopc c ty : t o� t h e H c a l l h D e p t. w� t h► n 6 0 D A X S a[ t c r t he`date of thc evaluation of
thc�sitc by:the.�-Iealth.Dcpt„,this.appltcation shall become vott��and all fecs paid forfeited.
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' � ' 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 shalt be issued until Authorization for waste water system construction
has been issued.
Tax Map # � ��
Zoning
Owner/Contractor���,��., �,n'
Subdivision Name
Parcel # I `� �
Township '8 �,�b h,�f ��i�1�
Permits may be voided if ' is alte ed o int
Well and Septic ayout by
Comments: � ti�$rrQQ >Yl(1A� ,
Date
�se.M �o �vc.
e ded use changed.
Approved by_
r%�l�-� _
Well Permit Paid �� WELL SYSTEM SPECIFICATIONS
Individual_�,�Semi-Public Required Slab _
Public Replacement Air Vent
Site Approved Required Well Log
Well Head Approved W T g
Grouting Approved� u�T f �
Comments:
Date
Installed by
�
Approved
'��' ��,�,�
�: r`i.
�
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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 environme�tal 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
�
,\
AUTHORIZATIOI�I FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: /D— ��9'g IMPROVEMENT PERMIT #: �S-y �{
TAX MAP #: : PARCEL #:
OWNER/OWNER'S REPRESEI�ITATIVE: �p � (`C�.�.�rvt� S �ri ,` a � `�
LOCATION/ADDRESS:
SUBDIVISIOIIIIAME:
SECTIOI�I OR BLO CK:
AUTHORIZATION
r
-�
�:
AUTT�ORIZATION CONDITIONS
LOT #: � �
. �
l. The Wastewater system construciion and installation must meet alI of the conditions of the
attached site plan and specifications as set forth in Improvements Pernut #��. The
constcuction and installation must also meet aIt applicable cutes and laws.
2. No portion of the Wastewater system shali be covered or placed into use untii inspected and
approved by the Person County Health Department. �
3. Any alterations in site or soil conditions (inc[uding structure tocations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and applicaiion, may void this authorization and associated permits.
4. Conditions:
Person Requesting: � �
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Date: v- � '
Own�r. '
Location/Dire tion �: _
Subdivision �Name: �
Drilling Contractor: _
. _..._ . . _ .,..'-_'
PERSON COUNTY ENVZitOIZMENTAL HEALTH
. ._ : . . � _ . ?� � Sc..�
. � 5 �.
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SR#
Lot #
. WELL CONSTRUC['IO'N --
DiStance from Nearest Properry Line /D Distance from Source of
Pollution /.GU ''
Total Dep.th: � G Ft. Yie1d:�U GPM Static Water Level S Ft.
Water Bearing Zones: Depth�Ft._ �r �' F� Ft� Ft.
Casing: Depth: From�_to 9�.- Ft. Diameter: Inches
TYPE: Steel - Galvanized Steel .�
If Steel, does owner approve: Yes No
� Weight�: � Thickness: /� Height�Above Ground: 6�i Inches
Drive Shoe: Yes ✓ No
Were Problems Encountered in Setting the Casing? Yes No ,i'
If "yes" give r�ason:
Grout: Type: Neat Sand/Cement �/ 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;- cuttinos) - Ratio: to
�ID Plates: Yes ✓ No � � �� �
�� 4 x 4 slab Yes�—No
�
I HEREBY CERTIFY THAT THE ABOVE INFORM�ITION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH $y�THE PERS0�1 COLi�1TY HEALTH DEPARTMENT. �
� � l� 3b-g� --
S gnature of Con�ractor Dat�
,
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1)
2)
;
3)
4)
Type III (b) System Inspection Checktist
Tax Map ,�i Parcel # : �� PIN
Owner: �j �r�`�'�r�ri�lQur�r� Subdivisian: �,1��1� ��` ��
Address• �o. "�,� I�ll�.5 Ph/Sec/Lot: a
Location:. Yell{, . P�:�d t-a
Establishment
a) type, size and sewage flow in
accordance with permit
Tanks _
a) tank risers accessible and surface
water diverted
b) tanks and access manholes structurally
sound, watertight
c) sanitary tee(s) in good working condition
d) tanks pumped, cleaned out as needed
Efflnent Dosine Svstem
a) effluent appears cl�, free of excess solids
b) required pumps piesent, operating properly
c) high water alarm present, operating
P��p�'ly
d) floats, pipes, valves, disconnects in good
working condition, operating properly
e) control panel enclosure and components
in good condition, operating properly
fl Drawdown rate:
Ground Asorntion Field(s1
a) no evidence of effluent reaching surface
or surface waters
b) surface water being effectively diverted
away from drainfield
c) diversion ditahes, swales, tile drains are
well �naintained
d) soil cover, vegetation adequate and
maintained as needed
e) protected from traffic and destructive uses
fl distribution devices in good condition,
working properly
g) repair area properly reserved, maintained
h) pressure head properly adjusted
YES NO NOT CHECKED REMARI�S
Summary of Improvements and/or Repairs Needed:
�� ��
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Authorized Agen � ti::� Date l a� 1�-1 cto