A30 131, Amount paid � ...��'�
' Receipt p '�a.i�'a'
. � � �6 ,� a
Date.
�' 1. Permit requested by: .
��
M owner/pros�_�agenl:
d Address: __ r .
C2 C]-. - o �
G
...� � Z� �'
w
Uc� Home Phone #1: � l�i — 7 3 a-` 7 g 1�
d usiness Phone �: ���i 19'.q�lZ-- 345 3
�.
2. Name and address of c rren
�a,. � . Q � oc
� �s�► ��k
� G�,
owner:
7: Dimensions or Proposed Slnacture: �.
r W Idlh:
M1 �
. Depth: 4 �i
8. Whal typc (if any, additions, expansions, or
, replacement is anticipated to the structure or facility
that lhis sewage disposal.system is�"intended to serve?
' 9: Water s. ply t}'pe:
private public� .community ❑ spring❑
c an wclls_ on ad'oining property?Yes 0 No [�
Ar y J
If�.so, �dentify.location:
� 3. Property Description: Lot size: I. 05 �- �
l
'� . Tax I v�a : A c 3 0� 3 0 � 1 0. T y p e o f s t r u c t u r e lfacilit y: Pro posed: Existing: Q
M arcel#� � � T Y p e o f d w c l l i n g: ' �
Q. P .
Township:-- �s• .- �✓ ' House:(� Mo bi l e H o m e: B u s i n e s s:❑ �
� Type,of business:
a�. 5.: Directions.to propcny:� State Road #& Road .' Nuc�tbe,t.�of Employees: - . .
ames,�tc.
� . f , . ✓c� � � l f � �'o✓ : Number of bedrooms: - — :
� � � Garbage:Disposal? Ycs O No �
' a3Se �4 �^ ��` � �M gasement?.YesO NoC�f so, # of basementfixtures:
E-' . ,;/), � L: ,�� �� . ,.. ..
]�� �.. , i .
� 6. .I�Iumbcr of occupants or people to be servcd. �� �, � ' � �
:� CLEAR�X STAKE;ALL. C O R N B R S O F� T H E P R O P E R T Y A N D T H E C O R r I E R S O T ALL
. ; PROPOSED STRUC�U�tES. �
I hereby make appltcalton to the Pet'SOri .C011rity T�ealth De�lartmettt for a site evaluation for the on-sic��
sev�_�ge disposal sysccm for the above described p.toperty. I agrec that the contcnts of this application are ccve
and:represcnt the<tnaximum fac�lilics� lo,be placcd :on thc'property. � I undcrseand if the site is altered or the
.� �intcnded use,changes;, thc��pertnit shall becomc inval�d ��:I uhderstand that before an Improvements Permi[ can 1•
~"• issued, I;musl ce,sent'a:sucve lat'oE the�� ro ci to the callh Dc G I understand that in the event I have nc�
p, , . YP p PeY :� .. P.
".� dcl_�vered'a sutvcy�.plat of lhe pioperty to l he Hea ll h Dept.'w� t hin 6 0 D A X S a fter the date oE thc evaluation of
'�'' the stte;by.the �-leallh:,Dcpt., this:appl�cal'ton shall bccome voi��and all fccs paid forfeited.
s . r .
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B 2575
• 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 # (�. Parcel #
Zoning Township l,(,5 h - �"
Owner/Contractor � � Date Ip- -�l $
Location/Address � Q, 52 T � � � �
� o s.x.# 113
Subdivision Name ` Lot# � �
SEWAGE SYSTEM
�ir Lot Area , I?
� L� - Mobile Home �
ness # of Bedrooms�
Permits may be voided if
Well and Sept' ayout by_
Comments: n
Installed
altered or
TIONS
Size of Tank 1(X �
Size of Pump Tank j
Nitrification Line �-
Max Depth Trenches
���bPvC
nded use changed.
��(R �f � v �%19 � -�Q�
Well Permit Paid �� WELL SYSTEM SPECIFICATIONS
Individual ��emi-Public Required Slab _
Public Replacement Air Vent
Site Approved Required Well Log
Well Head Approved ✓' Well Tag
Grouting Approved ��� � .� � � �
Comments:
Date
Installed by
L
Approved
by
.
This report is based in part on information provided theTiomeowner 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 ta�k 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
,�:,..,: �
u��
�
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: ���.�—�� IMPROVEMENT PERMIT #: �j o�S7
TAX MAP #: : PARCEL #:
OWNER/OWNER'S REPRESENTATNE: O l I'e �
LOCATION/ADDRESS:
SUBDIVISION NA.ME:
SECTIOI�I OR BLOCK:
; �.� 1� LOT #: � .
. � . ��
FOR CONSTRUCTIOI�I ISSLI.�D BY:
AUTHORIZATION
l. The Wastewater system construciion and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Pernut #�p The
constniction and installation must also meet aIt applicable rutes and laws.
2. No portion of the Wastewater system shall be covered o.r placed into use until inspected and
approved by the Person County Health Department. �
3. Any alterations in site or soil conditions (inciuding structure locations) or modification in use,
design wastewater flow, or wastewatec characteristics as specified in the associated improvement
permit and application, may void this authorization and associated pecmits.
4. Conditions:
Person Requesting:
���i'2�D
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i� ` �+ CQ�eloOme��
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PERSON COUNTY ENVIBO2IMENTAL HEALTH
WELL LOG
Date: v- - '
Ownet �
Location/Directions:
Subdivision Name:
Drilling Con�ractor:
. .. .. _ �- � �# �r �
7
_ . __ - _ .
SR# ' � •
_ -
Lot # 3
Distance from Nearest Properry Line /0 Distance from Source of
Pollution /G� ''
Total Dep.th:.�(�0 Ft. Yield: aU GPM Static Wacer Level aS` Ft.
Water $earing Zones: D�epth 7S' Ft. /3a � Fc. � F�._��,
Casing: Depth: From�_to Co.3 Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel �
If Steel, does owner approve: Yes No
� Weight: � Thickness: /� Height'Above Ground: <�i Inches
Drive Shoe: Yes ✓ No � :
Were Problems Encountered in Setting the Casing? Yes No � �
If "yes" give r�ason:
Grout: Type: Neat Sand/Cement_ ,/ Coricre[e
Annular. Space Width Inches
Water in Annular Space: Yes No
_ .. Method: Pumped � - � �Pr�ssure : � Poured_f/ ��- �. . . . •, _
Depth: From 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 �
Y HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
T�S WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH By�THE PERSON C�Li�iTY HEALTH DEPARTMENT. �
...� G -3�'--�4FT"-
..�Signature of Contractor Date
i
PERSON COUNTY HEALTH DEPARTMENT
SUBSURFACE WASTEWATER SYSTEM MONITORING REPORT
14 �� �' �o �►h 1yqt� � 3� 13\
Date of Inspection System Ins allation Date Type Tax Map Parcel #
�s� Y��.ow Q►a� �,1, �hicw� ���.s . �1,c, a�1sL11
Property Address
Instructions: Cl-,eck yes or no for appropriate items and explain in spa;,e pr�vided for remarks and
comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate
by "N" and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance
and monitoring items specified in the permit are to be carried out.
INSPECTION RESULTS
COLLECTION SYSTEM:
Evidence of leaks ?
Tank risers accessible, free of
infiltration and surface water diverted ?
Septic tanlc needs pumping ?
Inches of solids:
Septic tank filter cleaned ?
EFFLUENT DOSING SYSTEM:
Required numps areser.t & fur.ctional ?
High water alarm operating properly ?
Floats, valves, etc. in good condition ?
Control panel & components in good
condition ?
Eftluent free of excess solids 7
Inches of solids(pump/dose ): "
Elapsed time readings ? }.� LL
Counter readings ? �
Drawdown rate: ^—'
YES / NO
❑ � ❑
■ ■'
■ ■'.
❑ � ❑
DISPOSAL FIELD:
Evidence of effluent surfacing ? ❑
Evidence of effluent ponding in trenches ?❑
Surface water effectively diverted ? '�C]
Diversieas/sv�a:es progerly maintained ? ❑
�egetsti�e cevPr r_�ain*ained ? "�
Protected from h�c/unauthorized uses 7�
Di�triburion uevices iii good i:ondition 7�
Field ftee of settled or low azeas ?
/
/
/
/
/
/
/
/
�
►
■
■
■
■
PRESSUtZE DISTRIBUTION SYSTEM: j�
Turnups/cleanouts/valves/taps intact &
accessible ? ❑ � ❑
Pressure head properly adjusted ? ❑ / ❑
COMI'LIANCE:
Compliant
Non-compliant
Needs Maintenance
i�
■
■
REMARKS
S�Ci�c. '�4t`�►�\. �6�'
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5`isK.... MQ€.,Mc.s �ro C�. wo�Uut,�.�o �=��f1i . Pl.�� C�1vE. us a4
EHS �-u- R. .S�'t3�