A31 104No. of persons to be serve� ,,,�:
Additional appliances to be used: Disposal, dishwasher, washing.
machine N �O tl �
Recommended• Septic t8n1r �� ��� � Q'�� ��
Nitrification line: y� 7< <a �t�4"+ �( �, ,''�'� ��� f X (j
, .
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line mus! be inspected and
approved by a member of ihe District Hea12h Deparfinent staff before
any portion of the installation is covered.
Date Approved: `� - '� - L' •`
� , ISigne�
Sanitarian
`1 �By� �� �'i `
r
Countersigned
O. David Garvin, M.D., M.P.H.
District Health Officer
(Over)
NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on _
adjacent property, etc. Write in measurements in order that installations may be located at later
date.
SUGGESTED INSTALLATION (Date ) FINAL INSTAIS,ATION (Date )
(Road or Street) (Road or Street)
�ISM• !�r1+\
■��e���l��!��'!"'�""�n7El�■■ ■■����■
■��o■����Itl��iir�'ii�l�� ■���■�■
■����■�����i���ii��■ ■�■■■�■
■�����������������■ ■�■v���
■■���■����si����������■■��■
■�■■�■�■����i�i�■■��■■�■���■
■���������1��������1������■■
■��.■�■■�������e�■���■����
■�sN���r�■■������■�������■
■e�i�l��������■���■��■��■�■
■e�������o���■��■■ ■■■�n�■
, ������■��■������■ ���■■�■
�f
No. of persons to be serve� Q:•��=, "—z, :=, =•
Additional appliances to be used: Disposal, dishwasher, washing
machine R{ � � �
Recommended• Septic ta �
Nitrification line:
� ► P.� I ��L-,�.f n�
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line must be inspected and
approvesl by a member of the Dis2rict Fiealth Department staff before
- any portion of the installation is covered.
Date Approved: �— � — ��
By:.
Countersigned
Signe�
Sanitarian
O. David Garvin, M.D., M.P.i3.
District Health Officer
(Over)
NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on
adjacent property, etc. Write in measurements in order that installations may be located at later
date. �
. SUGGESTED INSTALLATION (Date ) FINAL INSTALLATIgN (Date )
(Road or street) ,(Road or Street)
��
/
No. of persons' ta be serve� ,,.
Additional, �ppliances to be used: _ Disposal, dishwasher, washing
machine + � ��j -
Recommended; ' � Septic tan . 1 �
_ , . —
. �. _.
Nitrification line:
Above recdmmendation � based on information received and observed
soil condition. Septic tank and nitrification line musf be inspected aad
approved by a member of the Disirict Health Department staif before
any portion of the installation is covered.
Date Approved: �-. �� �j �
� ^ Signed
Sanitarian
By; 3�1%
O. David Garvin, M.D., M.P.H.
District Health Officer
Countersigned
(Over) _
��
NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on
adjacent property, etc. Write in measurements in order that installations may be located at later
date.
-- . SIIGGESTED INSTALLATION (Date_
(Road or Street)
FINAL INSTALLATION (Date )
(Itoad or Street)
Y•
er�on Couety Health Department.
+ ♦ �` � � (�r� ^, � t tjell Permit
W � "� Vd `
DATE IS ED: "/ AT ;. ��UNTY: �w'
OWNER: D/STREET:
ADDRESS: �
DRILLING ONTRACTOR: `
NAME
WELL CONSTRUCTION .
Distance from Nearest Property Line Distance from Source of
Pollution �— 1
Total Depth: VFt. Yield: 1� GPM Static Water Leve Ft.
Water Searing Zones: D h � Ft.—�— F. Ft.
Casing: Depth: From�to Ft. DiamEyer: Inches
TYPE: Steel Galva i ed Steel��
If Steel, does owner app Yes No
Weight: Thickness:� eight Above Ground: Inches
Drive Shoe: Yes No
Were Problems Encountered in Setting t e Casing? Yes_No_
If 'yes' give reason:
Grout: Type: Neat Sa �ement Concrete
Annular Space Width L� Inches
Water ia Annular Space: Yes No )
Method: Pumped Pl�re Poured y
Depth: From toL�s•�% Ft.
Materials Used: No. Sags Poztland Cement Weight of
1 bag lbs.
If mixture (sand, gr�t�rel, cuttings) - Ratioz to
ID Plates: Yes � No
4 x 4 slab Yes� No
DRILLING LOG
De th
From To Fo ma ion De cri tioi
� �
I HEREBY CERTIFY THAT THE ABOVE INFORMATION ZS CORRECT AND HAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE TH REGULATIONS SET H BY THE
PERSON COUNTY BOARD UF HEALTH. V FT� REE RS.
/} �
�-�"^�' �MM���� (.�9 � Signature of Contractor Date
U /" �
/� \
/� S i arian' Signatur Date Issu d
Sanitarian's Signature Date Completed
Sketch well location on reverse side.
_ ,
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// ���I �
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' _ ._�''y__ `� :
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Y.: •
,
Yerson County Healtll Department
Existing Sewage System Report For:
� ile Home Keplacement , :;�?"
Addition
Requestee: -LC_-�' i�C�/1� 1-1 �i � J Home Phone#
�� �� ��.(,r%�7 � Business# J� � 7-�53�
��'�_� !►' � ol Z� 1�.� T a x M a p# f+' � � ��
Loca�ion/Directions: �t.��O��P �; ��5 � `�Z� �1"liOYl ��11e,�`.
� �� ► _ +�L1. � o k 1 �l�l � �� � �e � � �� �n'p�-
Original Permit Located
Septic System Uesigned For:
kesidential __� Business
# f3edrooms
# E;mployees
'T� E..� G`;��e�C� �� 1��.
Other (speci�y)
llate rnstalled Q-'�' �p� Water supply
`Pype o f System � n V Q�-�-�� ��� Q,�(,
Other
Nitritication Line 25`�(lP` _��{` k�i � 3-(�r>` k�`
Tank Size � �
Certified Operator Required �
�
On site wasLewater disposal system showes no visually apparent
malEunction on � F' �` g ZS
Yermission is granted to: �
According to the attached site plan.�
Comments:
Environmen�al Health S .
!� � ��9
DATE
o � `%
+Amount paid 1d6,� �9
Receipt.l� � ll
�
H
O
�
�
w
U
�
a
Improvements Permit.(EstablishedJRecorded Lot) I_
Permit (Unrecorded Lot)
provements Permit (Mobile Home Replace)
6-9-��
Date
of Existing System (Loan Closing)
Repair/Replace existing Septic System
Permit for New Well
Improvements Permit (Addition) � � �. I_ Replace Existing Well �
W
¢
z
.Permit requested by: .
ome Phone #:
usiness Phone #: �q 7' S5.3 g
% Dimension� or Proposed Structure:
Width: � �"
Depth: fo 0 �
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?
Name and addre&s of current owne : 9. Water supply ty pe:
j. � Vjh i��� c..� private�. public ❑ community ❑ spring ❑
-T—�,,� � e�. C� � Are any wells on adjoining property?Yes ❑ No �.
If so, identify location:
Pranertv Descrintion: Lot size:
Tax Map#:_ f� .
Parcel#: 1- d
Township: 1� u��
. Directions to property: State Road #& Road
ames,�tc.
�.
Number of occupants or
_ \ srt d v�
to be served: �
10. Type of structure/facility: Proposed: �Existing: Q
Type of dwelling:
House: ❑ Mobile Home: �1 Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �_
Garbage Disposal? Yes ❑ No Cl
Basement? Yes ❑ No� If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pei'SOn COunty Health Depat'tment 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 true
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 proper[y 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.
Sig�cc� Owner o� Authorized Agent
r �
Permit Issued ❑ Signature Date
Permit Denied ❑
Plat Observed ❑
4 ��..:3 /.�u . �n ... �' �8,w;' q t'... '(£ �°;,"`£�'�N�.`::A.�dL...::::. .:.I�i2.F.�...� ��,�s.::(r��$,'.f`.:�Kkh.x�•.�..''�" ./�Ad. 1.:.
i.
?:i`Yx:YSn�..,J C.r...r. F;" .b' F7�.f IVKS•STCEEVAI.IIAZIQ±I� . x..:. r.K<:.; : t F. C`. ?.. ":.'t'
1. SLOPE (%) S S pg PS
PS PS
� � � V
2. SOA.7FJCTVRE (�2-36 MJ S S S S
(SANDY, LOAMY. CLAYEY. NOTE 2:1 CU117 PS PS PS PS
� p p U
3. SOiL Si7tUC7URE (12•161N.) S S S S
(ClJ1YEY SOILS) PS PS PS PS
� U U U
3. SOILDEPTH(IN.) 5 5 5 PS
PS PS �
U � � V
3. RES'IRICTIVEHORiZONS(iN.) 5 S S PS
(IMPERVIOUS STRATA. ROCK) PS PS �
U U U V
6. SOiLDRAINAGF/GROUNDWATER S S S S
(EJCCFRNAL A Q1T ERNAL) PS PS PS PS
U � V U
�. son �w��s�un S S S s
(PERCOCAAT]ON RATE) PS PS PS PS
� � U U
E. AVAIU\BLESPACE S S S S
p$ PS PS PS
U U V U
9. SCCECLASSIFlCAT10N(SEEBELOW)
SOiI. SERIES
S-SUITADLE PSPROYLSIONALLYSUTTA6LE U•UNSUITABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRANI (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns� CtC.� C:WMiPRO�DOCS�APPSEC.5�1 FINANCE.PC
��..�-,: •:.
.
Yerson County Health Department
Existing Sewage System Report For: ✓ Mobile Home Replacement
Addition
Requestee: � �-�►�Od I ��� Home Phone#c���"`�%��
tl
3� l� l� t..c,(-" ��m � B u s i n e s s#
��X.�C'�'��. l V C-- `Pax Map# � f c�l "�d �
Location/Directions: ���� `�D �i�1 ►� Z7�'l l"5�'2�� ��c�,u�• �/L—
Original Permit Located �—
Septic System Uesigned For:
Etesidential '�
# I3edrooms
Business
# Employees
Uate Tnstalled ���
`Pype ot 5ystem �
Nitritication Line
Tank Size
Other (speci�y)
Water supply
Other
Certified Operator Required / �/ (�
On site wasL-ewater disposal system showes no visually apparent
malfunction on C� � �f ` % �
Yermission is granted to: �� �
According to the attached site plan..
Comments:
�
Environmen�al Health S�i.
l
I ► �f`
DATE
�. .. _ . ... : .'�. � . .
�GG,°v
Amount paid
R�ceipt li '
.y
� �- � .
Improvements Permit.(Established/Recorded Lot)
Ir�, provements Permit {Uncecorded L:ot)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
'7�.29-q �'
Date
Reinspection of Existing System (Loan Closing)
RepaidReplace existing Septic System
�_ Permit foc New Well
Replace Existing Well
n
. •. .. >. .�.,V. r,. .. .. � _.Y.►,,. ,....w..
ua�rP��a A Chemical Petroleum Pesticide _.L.ead
L.....----
i, permit requested by: . 7. Dimensions or Proposed Struc[ure:
5 y ��' , Width: / �
�wner/prospeccive owner/a ent: C�e� G�h �o —
Address• ��?CQ l /, �-� rG�a.�'+ !� Depth:
o - ? 3 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?
Home Phone # 33(0 - S� � -/S�oa
usiness Phone #: �'�'�'t �
I�Iame and addr f cutrent
i r � n� � � -
e r�I�'1/s f?�
. Propercy Description: Lot size:
. Tax Map#: � �' 3 � y`�"
Parcel#: G I 2�
Township: �. t�u�-d 1e- /� ` � S�
i. Directions to propercy: State Road #& Road
�dle ;�� //s �/�� �n l,�J t `s ca �'e-
�� .i _/_ 7nl��i-' Qf> I/Z
9. Watec su ply ty pe: --
private �. public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No [�.
If so, identify location:
10. Type of structure/facility: Proposed: �Existing;,�
Type of dwelling:
House: � Mobile Home:� Business: ❑
of business:
Number of Employees:
Number of bedrooms: �
� Garbage Disposal? Yes ❑ No �
D r� �w rc . �� e Basement? Yes ❑ No� If so, # of basement fixtures:
6. Number of occupants or people to be served: =
CLEARLY STAKE ALL CORHERS OF THE PROPERTY AHD THE CORI�IERS OF ALL
PROPOSED STRUCI'URES•
�I hereby make application to the Person COunty T.3ealth Uepartment for a site evaluation for the on-sit�
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 property. I understaad if the site is altered or the
intended use changes, the permit shall become invalid. I understand that before an Improvements Permit can t
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have no
delivered a survey plat of lhe propecty to alth Dept. within 60 DAYS aft the date of the evaluation of
thc site by the Health Dept., this appl' ation all become void an fees ai focfeited.
sj
�
. - - • - . . _.
'" ".._""....�� . '.- ,..;-..f . . . . . . . . . . . .. . " . �- �
Amount
'' Receipt
�
E�
O
�
V-
paid j00.
u ' lS(
� � r' --
'7'o2G -�I �i
Date
�
w
�
a
1. Permit requested by: . 7. Dimensions or Proposed Structure: '
- -----_.:.... ,......e��",P.,�• _ Width: 14- x 66 -
1, �- -� ��.vJ t2c� � "
'� ��-nQ 8. What rype (if any, additions, expansions, or
;.`,o -�� l� 1J 'C�—,�.'r7s �3 - replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
ome Phone #: 3 G�-' i ��'�
usiness Phone #: �
I�Iame and address of current owner. 9. Water sup 1 type: -� '
.T • r ����.�� e� � Nl . �-� _ �. private public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No Q.
If so, identify location:
Proper[y Description: Lot size:
Tax MaP#: � � 3 � Caw .��
Parcel#: • o
T,,.,,.,�ti;,,• �-��_' 1 e.. M� 1 �s
Directions to property: State Road #& Road
ames,�tc. �
. u���o� G-�c-4v�
10. Type of structurelfacility: Progosed�Existing: Q
Type of dwelling:
House: � Mobile Home:� usiness: ❑
'�jrpe of business•
Number of Employees:
Number of bedrooms: �
Garbage Disposal? Yes ❑ No �
Basement? Yes ❑ Noi�'r�so, # of basement fixtures:
6 Number of occupants or people to be served• �
� CLEARLY STAKE ALL CORI�IERS OF THE PROPERTY AND THE CORI�IERS 4� ALL
PROPOSED S'�RUCTU�tES•
�I hereby make application to the Person COunty T�ealth Department for a site evalualic tion ahe tnie it�
sewage disposaT system for the above described property. I agree that the concents of this app
and represent the maximum facilities to be placed on the propercy. I understand if the site is al[ered or the
intended use changes, the permit shall become invalid. I understand that before an Improvemeev nc have no
issued, I must present a survey plat of the property to the Health Dept. I understand that in the
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.
W �' � ^ �
� ._ �� . ..
Yerson Coun�y Nealtlt Department
Existing Sewage System Report For: Mobile Home keplacement ;���
Addition
� �/
Requestee: E��ri �,�,Home L'hone# =�{-����
� �`� � �, � �1� Business#
�� yyl�% I Q�,_ ��(�IG2�5�3 'tax Map# J�1 �l d� �
t I . . A r � „ ,nn � , I�m.,/ _t_.-, 1 / .�, �,, ✓� /�.� �
Location/Directions:
�.
�_ .
Original Permit Located �'
Septic System Design d For: �_
Kesidential Business Other (specify)
# I3edrooms # Employees Other
Uate Installed `7-%- ��. Water supply , �-(�JYY/YY�U,s�1, �
m .,,, p � r � v � r_ P m l ' .f� � I �Pi�2 �7�I�Y1Gd� � ---- i� %�LI [/1(� (?.�2 �(�Q�—
N itrif ication Line O�J �/� �� ��� �� - %S(� �X � _
_ �
Tank Size
- ' V �
Certified Operator Required ni(J -
On site wast-ewater disposal system showes no visually apparent
malfunction on � ��:� u
� n c . ,. A
Yermission is granted to:
According to the attached site plan..
Comments:
Environmental Health S��v.
� �� G �
DATE
.... _ ._. _.. . . . .,-., i �. . . . . _ � . . . . . . _ . � � . . ... . . . .. _ . . �
� Amount paid 1pp.ov
Receipt �� � ti l
. ��k thl
�
H
O
�
w
�
a
Improvements Permit.(EstablishedlRecorded L,ot)
Impsovements Permit (Un�ecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
Bacteria
� Permit requested by: .
wner/prospective ownec
�ddress: v �'�
11„n c��i �'1�/ S JV
�7 �Z,R-�t�
Date
of Existing System (Loan Closing)
RepaidReplace exis[ing Septic System
Permit for New Well
j_ Replace Existing Well
�'�+��4i�Ck?�.:ra=�+-t«.�.� .. �_ ._._._.._........ -
Chemical Petroleum Pesticide _ L.ead
7. Dimensions or Proposed Stcucture:
/aQent:S7tU� �, �/aRT�)�/ Width: � . ` li S G� � 1f
ome Phone #: S S�i-753 ,�
usiness Phone #: SC� � ' �s��
� 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?
I�Iame and address of,curcent owner.
, . � � � c': o � .l c Jl�. � �
erty Description: I.ot size:
Tax Map#:
Parcel#: _
Township:,
. Directions to property: State Road #& Road
iames,�tc.
,t .: ��.v���e N�; \\ s �.1 w� -%o
., .. . n.--,� na_ 1�
I�Iumber of occupants or
to be served: r
I
�. Water supply t} pe: - '
private �public ❑ community ❑ spring ❑
Are any wells on adjoining pcoperty?Yes ❑ No j�.
If so, }dentify location:
I0. ype of structurelfacility: Proposed: DExisting: Q
Type of dwelling:
House: � Mobile Home: [fl'�usiness: ❑
'�jrQe of business•
Number of Employees:
Number of bedrooms: �
Garbage Disposal? Yes ❑ No �!
Basement? Yes ❑ Noi� If so, # of basement fixtures:
�. � .
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AI�ID THE C4RNERS �F
PROPOSED STRUCTURES•
�I hereby make application to the Persott COunty Tdealth Department for a site evaluation for the on-sit�
sewage disposal system for the above described property. I agree that the concents of this application are true
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 undecstand that before an Im at in the event have no
issued, I must present a survey plat of the propercy to the Health Dept. I understand th
delivered a survey plat of the property to the Health Dept. within 60 DAYS aftec the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
, _ . . . . . _.
Person County Health Oepartment
Existing Sewage System Report For: � Mobile Home Replacement
Addition
� � � � i Qfi� ��
Requestee: �
�$�� cl ) (..c�� � �f:l
��x �r�, nrc� �7s � �
d ._
Location/Directions:
Home Phone# y �4 - 7S3'�
Business# �'D3--,3 �'� 0
`Pax Map#
Original Permit Located ��
Septic System Uesigned For:
ltesidential ,_� 13usiness
# t3edrooms # Employees
� � � , z� . C�-..
�-� ��k-u-e �
Other (specify)
Uate lnstalled � - Water supply
'Pype ot System
Nitrification Line
'Pank Size -3,b �
Certified Operator Required /1% d
Other _
lS0'�6 �
On site wastewater disposal system showes no visually apparent
malfunction on — — l� : ��
-� ; l l'► y � �c .�
Yermissio is gr�a�ted to:
v o�0 , /' � l � ��I
„�'�'r—e $ SsL(% i�l p-y�,,�—�` 3.�f— � _
�ccordinq to the attached site plan.
Comments: �' �� � � � X�
_0-� � --a
�
r �n� (� � 3 I� �
Environmental Health .`��C.. �) O X-� .1��G1 ir�✓L
DATE
N�v-03-99 O1s04P
��satton aats: 1 l -3-`1 `I
Am_ ount Fai„�-, o o,��
�ssa�s.���.�
Ps� Coun H� Ith De artmen
E vironmsntal ealth tlan
APPUCATION FaR S�RVICEB
P.O1
Iax Man �: � 31
�.�*: ID�
!j PrRnit r�que�ted by: (Owaerlagant/P��P�Uve own�r): N�� Y���(�f F ��51n1D
Home Phone: Address� `� �a r �v� �l,� .
Business Phone: _. �l-l�k _oX6T� t� f 1� '� ��73
2) Nam� and addnss of currant own�r: �� `T�1�Ll7�5 1Yl }} P— 2a�e�E WHrY�Cr�c�
LA�1� 5 s i-o _�_
u " 7�s
"' � 0.c��
�) Propertl► DesCrlptlon: �ot slzs: '` Towrutup: �5�y i�=UR`�
Di�ectiortf to the property (Indudin ro&d namea and numbers): 'T� ��t�} , � S'� $���
D �2n \ LS �R�c'' r�
`
�.� 2 � e�s �;. le�—�
4) Propp�d Use orld 3lrt,��re DeacNption: ancwer eaoh of the following questions:
a) Proposed n, Existin9�
b) Stidc Built u, Moduiar U, Single Wide yQ Double Wide r,:
c) Number ot Bedrpoms: ,� d) Number o( oca,pants or people to ba senred�
e) Basem�nt: Yeg r, No�"r,, If yes, # of basemont fixtures:
� Garbage Olsposal: Ys:� Nd� "—'
9) Dimenaia� of Proposed Structure: Width: � Oepth:�
5) Waber 3upply TYPa. Private�(new �� or exisbny�, PuWic u, Community !-!, Spring �
Are any wella on �IdjoininQ prpperty? Yes G No �if ygs, location
6) Pf��sa Indkate Ooairod System Typa: (systems can be ra�ked in erd�r of your prefet+nce}
._Canv�ntlonat �Modtf(ed Convsntional `Altemauve ,Innovative
oth�r (specity}:
CLE1IRLY STAKE ALL CORNERS AND UNES OF THE PttOPERTY,
8TAKE 7HE CORNFRS OF ALL PiZOP05ED STRUC7'URE$.
p��A8E 4TTACN SURV�Y PI,AT OR SITE Pt,AN TO TNIS AppLtCATION
I hereby meke applicaqon to the Penon County H kh be
�
�� ����b� ro 9 ee partment�for a s►te evaluation for the on-site sewage diaposal systam for
P Rsrty. ! e ree that the contents of thi� Iication are true and repr@sent the ma�cimum facitities to be
plaCad ort the property. I uriderstand if the aite is altercd or the inkndfd use changes, Ihe permii shall become invalld. I undersland
that as appacant, 1 am re�ponalble tor identifyinQ and markin9 P�P�Y linea, comers and meking the sita etxeas;ble for the
persorxtel o} the Pecson COunty Health Department to conducf th�ir evaluatlons. I underatand thet I am responsible for �otirying lhe
Heakh Dep■ M if my properly coMains any wsttarida aa desfgneled by ihe Army Corps Gt �nginecrs.
Owner or lspal Rep�esentative /� �� ` �
Dat9
PCHO, rsv. 70112N9
8
Yerson County Health Department
Existing Sewage System Report For: � Mobile Home Keplacement
Addition
Requestee: �'�bbie ��'1r'�F«-�� Home Phone#
�Eµ 37(0l Du�l�a�n R� ausinessn J`� `1-�yA7
`�i ox,boro.�ntc a�s�3 � �Pax Mapn
Location/Uirections: � �l1I l.F����s �D��� MaM�- I"�rK �� Sa�.��
�(anion G�o✓e C�,u�cti�e��'�'< s�,. ,�� .�/y Pa� K o� L
�
Oriqinal Permit LocaLed � ,
Septic System Uesigned ror:
Trui le r
Ftesidential E3usiness Other (specifyl ✓ �tn���
� Bedrooms # �mployees Other _
Uate Tnstalled �%'-%-�% Water suppiy COmvr�unl{� C�cl/
Type or 5ystem �j11J�.P��10/l� /
i
Nitrification Line Z �� �es �J`�� xL
2ank size �CoC� Gc-1 �an
Certified Operator Required /J� �
On site wasL-ewater disposaI. syste� showes no visually apparent
malfunction on � C-5� 9 %
Yermission is granted to: ��5'��ll I'l�c.� /�cn.ta/ �T u��tr�
33' �`n F�onf o F E'x �'S�t; ,-, %-a �' I�,-.
According to the attached te plan.
Comments: l4ddr�55 �a�' ��'oolC (-�olloc.� '�d,
Environmental Health �'�G..
.� .
,Y�i��::
t - j ,
..t..0 ., ±-� 'L. r.�T'_�,'�... _ . _
f-5-99
D EAT
0
K:
A licatlon Date: ! � 1 �� � � Tax Ma � � / � � D �
Amount Paid:
Receiat #: Parcel #:
� � ���� _S� I�I�]I�.� �1� .
3�' � - - _
_ � � �7'1� � �
1�aavaa-�aa�--�-" .esa�a.71 I�1L.o�.IL�I�a
APPLICATION FOR SERVICES .
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT FALSIFIED
CHANGED, OR THE SITE IS ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID. �
1) Permit requeste.d b:(Owner agentlprospective owner): � t Wh ~�1�
Home Phone: Address: � - 3
Business Phone: /-�,lSl-3�$$'C�.�f o�C�O l�l ,� -% S1
2) Narine and address of current owner: ���E
3) Property Description: Lot size: Township: Subdivision: Lot # 3
Directions to the property (Including road names and numbers): P�� P 3 ►mi�� B W� PnCE rlt Jc LS mxT,
� Je ch� K�Q - , � D,(l •
35�, f�b-t ��s nN E��r��f c��.�� 2A.j ot_c_ �n�to �c ucw�Y -�-m" w Lc.g��G-
�, c��,,.�� on rz cn� — oc�fl rne�k.�l�P_rvEw�y P,�ese�-t-,�
4) P'roposed Use and Structure scription: �nswer each of the follow ing questions: /y � �0 �
a) Proposed _, Existing �ype of Structure: S%w mo9r�E �mC Width:�_ Depth.
b) Number of Bedrooms: 3 Number of occupants or people to be served: Z
c) Basement: Yes , No �/ Will there be plumbing in the basement?
d) 6arbage Disposal: Yes . No ✓ .
5) Water Supply Type: Private ✓(new _ or existing�, Pulalic_, Community� Spring _
Are any wells on adjoining property? Yes_ No ✓ If yes, please indicate approximate locatiori on the
'site plan. �
6) Does your property contain previously identified jurisdictional wetlands? Yes_ No�
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH.THIS APPLICATION.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED. �,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED.
➢ THE SITE MUST �E READILY ACCESSIBLE FOR AN EVALUATION BY THE HEP►LTH DEPARTMENT
STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposai
system for the above-described property. I agree that the contents of this application are true 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
harnma invaliri�l
Owner or
��
�!—O
Date
PCHD, rev. 06127/02
:,
���� .� ���� �.���
.� � . � .�
",� � � �..J � � �
��-�a� � �,--f► �,--„-„ �a���..I1 1�ZL � �.Il. �7I.-a..
7Cax Map # �3\ Parcel # ��
Existi.ng Sewage System Report For. �Mobile Home Replacement
Addidon Type•
Requester.��� ���lZ � � � Home Phone# 5 +� " 51 �
{�,�,.�; �S� �,�4 � ���� Business # q19 - y5!- 3c�g8
'� '�� ,31�'3 i�-�b��, �c a�s-�3
Location: I S'�1 �b I'1i,�� �11s > � cr ( ,In �•. � G�. 'i� � � a,
c�c�.n. Q.�� '� � �w� �,} ��e. 1,.�� �-�
_ �
Original Permit Located: Water Supply: �uC�:►�
Septic System Designed For. � Resideritial Business Other
# Bedrooms 3���`^��x # Employees Other
"..r`:�'� aS x lo` $� x g'
System Type��+✓z-.�v�.Q 7Catik Size:� c�t� _ Nitrification Line: �' -15Z�' x l�'
Date Installed: q�`7- l97 Certified Operator Required: r1o.
�n-site wastewater disposal system shows no visual signs of malfunction on� -� � Oy
Permission is granted to: (�2Q�o,csZ �M-1� `�3 ca-�c-' '� L1
Comments: �a �►�e. 31�.� `�V.a`���.. 4�����`'2�� �4�-bc.�l��
Environmental �ealth Specialist Date: Q- 7^�Cx/
v j
:������ I�I�����
. � ��� ��
��.�.��.�mm � ���.�..� ���.�
5��. ��.���: �
Name�b�.�. 1�.��� . Tag # �31 Parcel # � �`�
` �'01 �a�I� • Se � n%Lot#
Subdivision � �
. � ,� `� �.�o`�
Authoriz d S Agent . Y- -�� Date .
° system comp�,nents repr�eser�t uppmximate�contours only. z7ie contr�nr must, fTag the systesn p,ior to
\ egia:s:ing the i�utallation to �arrur+e thatpmmpergr�ade i.r masntained
Scale:
G� ��".,��� . .
. � �acQrv�s�.�- �� �`�o,��
� J
-� 1�� � 3 � -�k �-1.
, ��,� 5 � �
��
��Z s��.
� � �5 ��
.� � ��—
r
,� � � �M c,,o�Q� , .
��
�
�
r
Pc�, �. 09/�/oi
�.,•'
Person County Health De artment
��t �+��.(al6 �1 ��I �a�
Existing Sewage System Report For: V Mobile Home Keplacement
Addition
1�►) ��_� �/
Requestee: ��I � Vv �I 1�����/ Home Phone#
---�-,.
�]�� (%Q, � Business# �1����
���,�i`� N � �� /3 'Pax Map# � r ��I
Location/Uirections: �� 1 "� �L�1� �����+��
� � �— �6�.�.�.-_. � 1�� �,P� �� i? 68�I�flt.J�- (� - /.
�, o..
Original Permit Located �
Septic System Uesigned r'or:
Kesidential _� Business Other (speciEy) _
# F3edrooms # Employees
Uate lnstalled '"�O� Water supply
'Pype ot Sy
Nitrificat
Tank Size
Other
.
Certified Operator Required �V(�
On site wasL•ewater disposal system showes no visually apparent
malFunction on
Yermission is g
According to the attached site plan.
Comments:
Environmental Health $�C..
p� �bi l3) q�
��
.,c,c,-�. l Zrr � ���.� �
�1
DATE
� . �
T0:
f�tOM:
Freedom
HOMES
A Leader in Jhe Manulectured liaainp lndustry
ROBBIE WHITFIELD
Inventory Manager
3970 Durham Road • Roxboro, N.C. 27573
336-597-5538 • Fax 336-597-5822
: �
. UIu;ENr fYl PIEASE �EVIEW 9� CAU �
. COMMENf�
� THIANIGYDU Illl
3970 Durham Road • Roxboro, N.C. 27573 • 336-597•5538 • Fax 336-597-58?2
00
Amount paid _ � 00. �
Receipt .� ' �a,QLf
� �}2 ! � 8�
�
H
O
►.a
�
w
U
�
a
`�-�z(-q8r
1 Date
Improvements Permit.(Established/Recorded Lot) �_ Reinspection of Existing System (Loan Closing)
Impxovements Permit (Unrecorded Lot)
improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
Bac[eria
1. Permit requested by: .
�wnerlprospective owner
ome Phone #�
usiness Phone
Chemical
0
f lO�
2. I�Iame and addre�s of current owner:
Repair/Replace existing Septic System
_. Pecmit for New Well
_ Replace Existing Well
_ Petroleum
11►
Property Description: Lot size:
Tax Map#: /� 3 �
Parcei#• � � b �h � ��'
' '� M�P
Township: � . �
Directions to property: State Road #& Road
� 1 d �c-o:, t-e�.
_; �- - 1� e
Number of occu
_ Pesticide � ____ Lead
7. Dimensions or Proposed Structure:
Width: I� '
_ . rY111
oW� ���
�e�r � wi E-�. � a �.l
�� O\� 1 � SAM�
� or neop e to be served:
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that.this sewage disposal system is intended to serve?
9. Water su,pply ty pe:
private �� public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No p.
If so, identify location:
10. Type of structurelfacility: Proposed: DExisting: Q
Type of dwelling:
House: ❑ Mobile Home: 0 Business: ❑
Type of business: -
Number of Employees:
Number of bedrooms: �_ �
Garbage Disposal? Yes ❑ No �
Base ent? Yes O No�If so, # of basement fixtures:
sPo�-
CLEARLY STAKE ALL CORI�IER$ OF THE PROPERTY Ai�ID THE CORI�IERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Person County T.3eSIth Department 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 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 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 af[er the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
S��'nca Owner or Authorized Agent
C
n
Person County Health Department
�C�-�l� W I� � �e.Qc{,l•l l-Cf� : : .:
Existing Sewage System Report For: _,]�bile Home Replacement ;�x`�
Addition
Requestee: � �(��� � � ( �S Home Phone# � -� �]y��
l3 � ���PC�bW ��O�U � �('• Business# � � 9`� $3-�7 D(o
� � � a -f- /�/G � � 'rax Map# 1�� � - In�(
Loca�ion/Directions: � 5� t"U u-�'l��N� ��- � �
�� (� 1� �-� n i� w l l_ l�l �T� � i� ��� h� b n I-�� � �v l�
� l Z�
Original Permit Located ✓
Septic System Uesigned For:
Kesidential Business
# Bedrooms
# Employees
Other (specify)
Other
Uate Installed ���'" �i Water supply �,�ii')il��/ia��
'Pype of System �UYI � C�'M�0/1(�
Nitrirication Line �'J �X�o � � y �� � � �Sd 1 �� �
Tank Size
U n�
Certified Operator Required �v u
On site wasL-ewater disposal system showes no visually apparent
malfunction on � q/�� /7 0
Yermission is granted to: l�t��/L�l� Q C� �`►\S
According to the attached site plan..
Comments:
Environmental Health S�
l%
DA