A31 12<. .
A 0011�+�+
PERSON COUNTY HEALTH DEPARTMEN'�
WELL AND SEWAGE SITE, LOCATION Il�IPROVEMENT PERMIT
Tax Map #� Parcel # iZ
Zoning Township .� �
Owner/Contractor�,,.,�-���� ,,�iz,4DsN�iZ ➢ate Z.
Location/Address �y�„s,. /s7 � % at/ 4vEss �D
� � �c� �.✓ GEfcr-- S.R.#�
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area , Size of Tank /000 l,d L
SFD Mobile Home _ Size of Pump Tank ,v/�4
Business # of Bedrooms_�_ Nitrification Line y-oc�' x3 '
Max Depth Trenches "
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Pernuts may be voided if site is alter d or intended use chan ed. �J��j
Well and Septic Layout by - ��� �
—� � ,, 1
Comments: c�ow ,s � —
�
�
Date l� I/ - 9'% Installed by ' Approved by Gv.�-� �-r�—u-,�
WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab !/
Public Re acement Air Vent r/
Site Approved Required Well Lo� .r
Well Head Approved Well Tag �
Grouting Approved N�i` � ��a.o�.,,�-4-oQ
Comments:
Date r� //- g% Installed by���,� GUo� �'9> Approved by Gf "p1� ,� �.,,�
This report is based in pazt on information provided the homeowner or Ivs/her representative in the application submitted for Uus pennit The
environmental health specialist is not responsible for false or misleading infoanation contained in the application The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in Uus report that may have resutted from false or misleading
statements provided to him in the application. Neither Person County nor ihe environmental health specialist wazrants that the septic tanlc system will
continue to function satisfactorily in the future or that the water supply will remain potable.� c:�amipro�pennitsam Ol/95 rev.1.0
N
� bl 0�
M�Zy �Ee
�,� - --- �_
J
;'� � 0�� -" � l � � , . ,� .
�n o
� ~ 9/� p� � ~ y�h ✓ ' � I �
N a-- �
� �
�O � � -1 �
�
vr m /1� • • N2,�e Oq 4
�1y� � e,� 2
�' g��N
�0
.ir ���� � t � N19�5,� 1b �
oli
� � Z ,.
�
��, � ;, .
i .
/ 43' �� +� I � 3
/ �' N2o° 21' � o 0
� �49• �O �� . �oi
� �Fj� �s;,:
"� N� . � :
�
Z
Nz � .
/ '/ � 4 �,�� �?i�, of d��`�� 2 ��4�'3':
'/! . `� ��` '� 4�Sf��^.'� .jE�+(�' .
� i . �I�7' `y�,`�' i � � a'ff; 'c�
7��q(���� , .
' �/ • r4i 1� t:y��i���L.-.�, ��..� '1'}�`�g '
: ���t,� ;; y .. ..
S�
�'. ; i
� . � 4i��:
�tk...t.:-/''.�• 1
� ��'r':,ti,i �.• iYSi
. '��
, �`
. .n ,
`� � ; `: �: �; ��f� , ,, � .
�.�
:;:��'�:�x �-' -
� . n't
�:
�.4. .
.+ �'
i'� �i.
;�
, " . "�r�,�t,�,
' : 41.
9�
N �',���j • ' /
.
�'
�
w
•
PI:IZS�1N COIIN'1'Y I�:NV:I:IZOPJP�:iN1'l�1, ��);nl,�'��
_ . ,.
lJI':I.I, Lp(;
;.� �'.
• t u �'{7
. .. `:�,4,
':7£:
i �s;.
� \.^ku
Da te: --� —1 -� �' .:,..
Owner: �� � ;;;
� � SR#� � � . ,
. _ -���- - _ --- ------- ,�.
Location/Direct�or : ---�-�-� ._/s 7 _ _ - �/��=�--�� : ;,�
/ .�L
. • . . -- _�'__ -.......-
- �' �Fi.
� ub? �vlsion N�u»e: _ __ ._ _------- • � -
Drilling Con�- �-• --- --�- ________Lot�# � :�-
acto � _ _.__.
_ . �i.s—l�c._L1 Ca - --__ , • -•:x�`;.
WEt.i, C(�NSTR11= �
Distance from Ne�u-est Prol}erty Li���� /� l�_c__. Dist.�ncu from Souree o 5�
Pollution � � � � . f • �':'���'
,� ,..
Total,Dep.th: Ft. Yicicl: , � � 'r
Water Bearing '� ones: lle t}1 --- �"���--- --- �'� M Static Water Level � �F�. `,,.;
Casing: Dep � P�a�_---1_�t._ �3 Ft. F[. � I,.
th: From c� to -- -----�t. ,
TYPE: Steel .---'�-_--�'�• Diametcr: �� � Ynches ;�`'
� Galv�ulizcd Stecl '•`��
I.f S tee _. c..� . . ::,,�.
1, docs. owncr approv�:: yc=;_No . �. �,�'�'�
,
Weight:�_ Thicl:ness:.-�B�::Hei ht Abo � ;f'��
Drive Shoe: Yes�_ N�� � Ground:���ches �,;:,�L•
Were Problems Encounterec! in Sc' ttiil � � ��y�T �
-----_._. ,,:;
.I�' „. b thc Casin�`I Yes � No � �l�x:�
,�yes grve reason: --_____ ;�;r
Grout: Type: Neat S:��id . .,. • t..,;��;�_>
/Ccntcnt ; zt��
Annular. Spacc Wi�tl� 3 —___Concrete . �.f,
Z11C}1CS ''�
Water in Annular S — ` . `�`�'�
pacc: .��,
Y��s_________ No t�- , .G:�+
���� ,;,;
. e[ho.d: P11I71I�CC'4.____ I�C(:SSllI-C; j-- . `Y='�
Dcpth: ___ -------_ ourc�ci� � _ .. � �:.:t:�
From__�--- t��___--_�d I:� — . . �,;,
Materials Usc:ci: No. Ba�;s .l'ortlancl Ccmcnt • �''
Wci t�of .1 � �'�'��
If mixtui-c (sand, �ravcl; cutti )- Ratio: -�- �' ba��-lbs.;;,,�t���-
�
ID Plates: Y��s � N� nG� --�-.-_..`to ;'�'�``$,M t
. � --�- .._ .. . �
x 4 slab Yc:, ✓ No ,
_... ; Y:
j HEREBY CERTIFY �I'HAT TI-IE A,I3UV� ZNFORMATlON IS CORRECT AN i`yr
T�S WELL WAS CONSTRUCTEll �N ACCORDA,NC D THYAT� �
��RTI� �3Y�THE PERSON COUN�'�' I-II:ALTI-I DEPA TMEN�I REGULATIONS SET xs;
. . . . . � . . ' gYl
t `:3
. . • .. . . - ! .
a
'""""__'.""t�(111a.-� =.___ �W
.Sir;nalurc of� COI1�iI1CI01�
��
Datc `''
Appitr.ation Date: R� � Z Tax fltiaa #• � 3�
Amount �aid• __Q�� � �
Rec���t #: 2,�G r Parcai �:
��0� �� � � � �
�. �. � I� IL�.. � , 1,�,-a�
— — : - - - — cC � �Tl�T'I� �Y � r,�� Cu,
��.�sia-��---�-^- .e�m.��.71. ��Loa.71�11a %` , l� `I
l) w � �+ ,� ,�
� �/� 1
APPl.ICATION Ft3R SEiiVIC�S � N
IF'�'HE INFORhflAT10M IN THE APP�:ICATION F�R AN IAAPRO�IEMEWT PERAAIT 1S 1NCORRECT. FALSiFiED.
Ct-IANGED OR THE SITE IS ALT]ERED THE3V THE IMPROVE�IIENT PERMIT AAID AUTHORIZATION TO •
CONSTRUCT SHALL BE�OME INVALlD.
1) Permit requested by: (Ownedager�t! rospective owner): � 5�1 e✓ � J r�1 �S h e'?�
Home Phone: 3(,�� f - 3� O 31p� -,i� p Q y Address: a� S
Business Phone: u.r S , C. 2`l S'S//
2J Name and �dciress of current owne� � S ,. �v ra d s 2 Y'
' �es '
• , . -�f� .
3) Property Descri�
Directions to the
4) Propos� Uss and Structure Description: answer eacfi of the following questions:
a) Proposed , Existing , Type of S4vcture: Width: � Depth:
b) Number of Bedrooms: Number of occupants or people to be served: �
c) Basement Yes , No Wilt there be plumbing in the�basement?
d) �arbage Dispasal: Yes No _
5) Water Suppiy Type: PrivateV (new _ or existing_}, Pu61ic_, Cammunity� , Spring _
Are any wells on adjoining property? Yes_ No _ tF yes, please indicate approximate lacatiori on the
� site pian.
6) Does your property contain_pr+eviously ider�tified �urisdictionai wetlands? Yes No �
Pl.EASE NOTE THE FOLLOIMNG:
➢ A Pl.�T OF THE PROPE32TY OR SITiE PLr�iN NIUST BE SUBMITTED WffH Y6-IIS APPLICATION.
➢ PROPERTY UNES AND CORNERS MUST BE CLEARLY MAR4aED. �,
9 THE PROPOSED LOCATION OF �1L1. STRIJCTURES flAUST BE STAiCED OR Fi.AGGE�9.
9 THE SITE MUST �E REA►DILY A�CESSIBLE FOR AN EVALUATION BY THE !-IEE�►►i..Tii DEPl�RTMEiVT
STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal
system for the above-described property. i agres that the contents of this application are true and represent the maximum
faciiities to be piaced on the progerty. I understand ifi the s�te is altered or the intended use ct�anges, the permii shall
become invalid. . _ .
�
Cwner a�
��d2
Date
PCFiD, rev. �6127/02
���.s� ���.���
�--1= -�-.�- � � ���°�
IE�.�a-��.���.��.IL IHL�.�.Il�1�.
WELL PERMIT
PLF.1lSE SEE ATI'ACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: � Parcel # � Townslup
Applicant:
Subdivision• Section• - Lot•
��U� J- lF �'�:� JC��' • ��l �s�
Twe of Water Su�nlv: �. Individual Communitp Public
Rec�uirements• �
.. �� S
Site Approved by •� /o -�s-� z �
Grouting Approved by �,�,. � ��,-�1�,
avell Lo��S ,�-��-J=- V�'�K'
We11 Tag . . � � .
Air Vent
Hose Bib �
Concrete Slab • a `�
Well Driller. i:����
Well Approved Bp: Date:
'�°kSee Attached Site Sketch**
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Welis must be at least 25 feet from any building foundation.
Other conditions:
PC�ID, rev. 09/�7/01
� ����:�� �I����� _
_ � � �-���
IE��a-�� � em.¢.�.Il IE�T��.1L�1�
� ' a �I i
,•�- � �I.
.. • . ,I �
�,ir11 �a'' '
��. -. � .-�
SITE SB�TCI�
Ta.g Map #� Parcel # � �`
Section/Lo
� �� �
Date
System components represent approximate �contours only. The contractor must, fTag the system prior to
beginning the installation to insure that�liropergrade i.s maintained
. �u,� � r���� ��
_ —�
� � � �.
I
�
�
�
Scale:
��
��, ��
�
PGHD, res*. 09/12/Ol
S� `�'�
p°
�q, �-oY,
__
��--���, �� .1.C" �,11'�.� �.�. � Dr��(karr aD � � � 3 �
� '�� �C �OO ZC�� `�IC' �r ��� G�aGu�o cF�.r 1,.J, f�L'• I I- n�
�
� u.��7in �v�lrn.un:n.•�ii.�i.i(;..:u.11 �.�.��C.::n.�lil:v:n. � 'IJC�JlSI� �UU�lll�l°J � d. �.���a ]—
�,_��� �Veu �Og
Owner: �__ _�e-T�r�tc� S �.- ,An-��aw�y �,-,�� ,�,- Tax tVlap � P�u'ccl f� ��
Location. �_11l- F �1—r � LLIr d. �C /� Jlr ,p
�,��_ � �}� e- � c S /C
Subdivision: Loc 1�
Wc1I Coxistz•uctioxi
Distance From ncarest 1'roperty Linc (Minimum 10 fe:et) �
Distance from Septic System (Minimum 60 iect) ✓ ��
Total Depth: �6� ft Yield: �v _ GPM Static W:iter L�vel: _��� (i
Water Bearinb "Loncs: Dcptll � tt ��_ i't /��_ it ft
Casing:
Depth: From �_ to �.� ft. Diamcter: —& ��, in
Type: Galvanized Stcel -�-
Weight: �_ Thickness: �� Height abovc Ground: � in
Drive Shoe: ✓Ycs No Aaiy problems encounlerccl while setlinb ca�inb? iYcs �-P�10
If `�es" give reason:
Grout:
Neat: Sand/Cemei�t ✓ Concrctc Gcavel/Cemcnt �
Aririular Space Widtli � inches Watcr ui Anuul�u Space Yes �o
Method of Grout: Pumped Pre;ssure �oured Deptli ' v to �- � Pt.
Matez-ials Uscd:
No. Bags Portland ccment Wcibht of 1 I3aU ��f Pounds
Ifmixture (sand, �ravcl, cuttings) - Ratio � to �
ID platcs: �Yes _ No 4 x 4 slab t/I'c;s No
llrilliu�; Lob
Locatioii llr�wi���
rrom •]Co � roruiatiou —___"..__
0
�
� � � .
� � -�
,
�
I hereby certify that the abovc information is correct and tliat this well was constructcd in accordance with re�ulations
set forth by the Pcrson County Healti� Deparhncnt.
Signaturc of Coutractor Ill f� � 3 1 Datc �/ p_ f�_� �
' � PCIiD rev 01/16/02