A31 129Appiication Date: � � � � I
Amount Paid:
Receipt #:
Tax Maa #:
Parcel #:
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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 requested by: Own r/a� ent/ rospective owner): �.�1. J4-� �
Home Phone: ���e—� �- `` 1�y,�� � Address:
Business Phone: g� �$'I t`� �S S V11 �, j
2) Name and address of current owner. �
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nc• . . . �
3j Property Description: Lot size:�� Township: �_ ubdivision: Lot #
Directions to the property (Inclu ing ro ames and number ): �P `� �5�
5, L T �
i�, s.,,'d. �
,���K�' 4) ..Proposed Use and $tructure D� cription: answer eact� of the f�lowing questions: � "i �
a) Proposed _, Existing �pe of Swcture: �a.a � c Wid h:� Depth:�
b) Number �f Bedrooms: _�,; � Number of occupants or people to be served: �
c) Basement: Yes� No � ill th�be plumbing in the basement7
d) �arbage Disposai: Yes �N _
5) Water Supply_ Type: Private � (new _ or existing�, Public_, 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 v
� —
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED.. ,
➢ THE�PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTAAENT
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 agree that the contents of this applicatio.n 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
Owner or Legal Kepresentative
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Date
PCHD, rev. 06127/02
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Lots � � $ , � �
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_ Improvements Pecmit. (Established/Recorded Lot) �_ Reinspection of Existing System (Loan Closing)
Impxovements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
_ Repair/Replace existing Septic System
Permit for New Well
_ Replace Existing Well
Permit requested by:
Dimensions or Proposed Structure:
ner/prospective owner/agent: �v.� Width: -2 � � —
dress: � y 1� �.�-v�- S�-+��-`�' Depth: � S ��
:ome Phone #: � �S(o �� �a � C � � g
usiness Phone #: � (- isfl�� �l �i—� 4 �'b"
Name and addre�s of,current owner:
. Property D
. Tax Map#:
Parcel#: _
Lot si
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 supply t5•pe:
private ��public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes 0 No �.
If so, identify location:
10. Type of structure/facility: Proposed: �Existing: Q
Type of dweilin :
House: obile Home: Q Business: ❑
5. Directions to property: State Road #& Road TYPe of business:
ames,�tc. Number of Employees:
� ' Number of bedrooms: ..�_
� , -� � � Garbage Disposal? Yes ❑ No [�
Basement? Yes ❑ No�3-I�o, # of basement fixtures:
6. Number of occupants or people to be served: �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
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 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 al[ered 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 after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
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PERSON COUNTY HEALTH DE�'ARTMENT
VVELL AND SEWAGE SITE, LOCATION IMPROVEMEN'T 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 # 1 �- %
Zoning Township $-u��, �'B2�
Owne /Contractor ` w —� Date 6 — / —� $�
- . . - - - .9 ►7 _ A / � n� _ /� _ . .L
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot �a . $ � �A' Size of Tank � �''
SFD�/ � Mob� ome Size of Pump Tank1 B�O—
Business _# of Bedrooms �3 Nitrification Line �cap �X3 �
Max Depth Trenches 1 Ss «
Permits may be voided if site is
Well and tic Layout by l�fi.
C o mm ent��py�„ �r�-,�'-��arz
or intended use c anged.
� .,G(or�vriv���.
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Date � i Installed by LeD�a� (�'Bc`1ct,rti4- Approved by '_ �
-��.,..�'� �� I i � q 8
Well Permit Paid % ELL SYSTEM SPECIFICATIONS
Individual t� Semi-Public Required Slab �C
Public Replacement Air Vent �
Site Approved Required Weli Lob Ci�/ 4�
Well Head Approved Well Tag �S
Grouting Approved � c
Comments:
Date �"�%/ /�� Installed by �.(� �fQ���1 Approved
� This report is based in part on information provided the homeowner �r 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 remai� potable.
c:\amiprolpermit.sam O1/95 rev.1.1
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