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PETZSOPJ COUNTY HEALTH DEPARTI��ENT
WELL AND SE�VAGE SITF, LOCATION Il�ROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issua�d until Authorization for waste water system construction
�as been issued.
Tax Map # � 3� Parcel # � y s-
Zoning t. �: ►1 � n �. 12 U. � TPv�nship Rv_ sl�y �o,�'�C
Owner/Contractor � 5, ' -Ty`r�'�"�"�� -� Date ,� z�-9�
Location/Address�y, ,�� , s y ,�, , « �� �� ,.., � �� � ,,,, � H �-
���� S.R.# �s7
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area ,// _S-7 AG Size of Tank ��o� �rA �-
SFD � Mobile Home Size of Pump Tank �tl,c�
Business _# of Bedrooms� Nitrification Line y;�b f x �� �
Max Depth Trenches�v ,�- z s+ ''
Permits may be voided if site
Well and Septic Layout by�
Comments: ,�lo,� i,A�,. <
Date �- - (���
or intended use cha ed.
� - r.L�
�o ,. _ „
Approved b
W�II Permit Paid WE�,�, SYSTEM SPECIFICATIONS
Indivicival S�r;ii-Pubiic Required Slab Co�o1 l
Public Replacem�nt Air Vent �o
Site Approved ,/ Required Well Log
Well Head Approved L(a�4$90C Well Tag � o-� �-`� 7 To C—
Grouting Approved t o�� I-R h 50 C�
C��mments:
Date 1° )�/ g� Installed by ���� Approved
This report is based in part on information provide;i the hon��owner or his/her
representative in the application submitted for this permit. The �nvironmental
health specia�:st is not responsible for false or misleaai�g informati�n
contained in the application. �fhe environmental health specia�:st is also not
i•esponsible 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 environmenta� health
specialist warrants that tt�e septic tank system will continue to function
satisfactorily in the futur� �r that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
T � o� � � Tax iV1ap #:
Aupl�cation Date:
Amount �aid• . U D
Recaipt #: Parcz! #:
+ � � ' ���_ `�� ���.� ��
d � � ����
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APPLlCATI�PI FOR SERVIC�S
IF THE INFORMATI�M IPI i'HE APPl.1CATION FOR AN IMPROyEflflEPIT PERMIT IS IfdCORREC�'. FALSIFIED,
CHANGED OR THE SITE IS AL'fERED TFiEN THE IMPF�OVEt1AENT PEiRMIT AiVD AUTNORIZ�►TIOfd TO
CONSTRUCT SHALL BECOME INVALlD. C
,°1 1 �-
1) Permit requested by: (Ownerlagentlprospeciive owner): W � � e��� Sfl ^�
Home Phone: �� (. �(-7 S�SG Address: � � ��
Business Phone: �� p�� 1 t� y 1� �� �c � r'
2) Idame and address oi current owner.
3) Property Description: Lot size: Township: Subdivision: Lot #
Directions to the property (Including road names and numbers): � � ,,� �
4) �roposed Use and Structure Description: answer each of the following questions:
a) Proposed _, Existing , Type of Structure: Width: Depth:
b) Number of Bedrooms: Number of occupants or people to be served: �
c) Basement: Yes , No Wili there be plumbing in the�basement?
d) Garbage Disposal: Yes No _
5) Water Supply Type: Private �(new or existing�, Pubiic , Community , Spring _
Are any welis on adjoining properiy? Yes� No _ if yes, please indicate approximate location on the
�site plan.
6) Does your property contain_previousfy identified jurisdictional wetlands? Yes_ No�
PL�EASE IVOTE THE FOLLOWING:
➢ A PLAT OF THE PROPEf2Y1( OR SITE PL�►iV MUST SE SUBMITTED WITH THIS APPLlCAT10N.
➢ PROPERTY LlNES AND COR(dERS MUST BE CLEARLY MAR�QcD. ,
9 THE PROPOSED LOCATION �OF ALL STRUCTURES MUST BE STAF(ED OR FLAGGED.
9 THE SITE MUST �E READILY ACCESSIBL� FOR AN EVALUAl70N �Y THE liE14LTH DEPARTNIEAIT
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 application are true and represent the maximum
faciiities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall
become invalid.
.A� �n , n �
Cwner or Legal
L�: . , ..
�_ -
PCND, rev. 06127J02
'\� ;;�,� �����d. V
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SiTE SI�TCI-I
Name �/ ( � �f �l ����Lt.s�}Y1
Subdivis '
� ���
1-luthorized Sta.te Agent
Tax Ma.p # � � .Parcel # /� s
Section/Lot#
�—��a�
Date
System components represeni app%�imate�contours only. The contractor must. flag the systemprior to
beginning the installation io insure that j�roo�iergrade is maintained
Scale:
k-�,J'`e,
�
�t- �-t- 7�—"�'`--�- �-1�
PGHD, rev. 09/12/Ol
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-�.-i na�was�sa�a.�n�.2�.]! �1La��.Il�E11�n..
�UELL PERMIT
PLEASE SEE AT"TACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: �� Parcel # �� S Townslup
Applicant: � �
Subdivision• Section• Lot•
T�e of Water Su��ly: ,� IndiPidual Communitp Public
Req�irements:
Site Approved bp �/ 3� � a3 ��"
Grouting Ap roved by 3 t� �' a 3-oa
Well Log �� � 9 a3-oa
We11 Tag
Air Vent
Hose Bib
Concrete Slab
Well Driller.
Well Approved By: Date:
'�°kSee Attached Site Sketch'�°k
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from anp building foundation.
Other conditions: �
PCHD, rev. 09/07/01
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D�Oc� �D � �I�;�� � I
C�o�p� a� ��, .' \.� L� L�
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Well Log
Owner: w, I li a� ���.�,' ��i 1 Tax Map � Parcel # l�I
Location: �S�OcX? f-���r�l �� 1�;.J 1S i2�1 .
Subdivision: Lot #
Well Construction
Distance From nearest Property Line (Minimum 10 feet) I� f
Distance from Septic System (Minimum 60 feet) (�Ofi
Total Depth: � S ft Yield: �) GPM Static Water Level:
Water Bearing Zones: Depth <-/�b ft ft ft ft
�
Casing:
Depth: From � to �-I ► ft:�/a.Diameter: �o � c in
Type: Galvanized Steel l�
Weight: Thiclmess: � n I�!� Height above Ground: � in
Drive Shoe: Yes _�I�o Any problems encountered while setting casing? _Yes �No
If "yes" give reason:
Grout:
Neat: SandlCement
Annular Space Width
Method of Grout: Pumped _
Concrete GraveUCement
inches Water in Annular Space Yes
Pressure Poured Depth
Materials Used:
No. Bags Portland cement Weight of 1 Bag Pounds
If mixture (sand, gravel, cuttings) — Ratio to
ID plates: _ Yes _ No 4 x 4 slab _ Yes _ No
No
to Ft.
I hereby certify that the above information is correct and that this well was constructed in accordance with regulations
set forth by the Person County Health Department.
Signature of Contractor . ID #�-e 7� Date 0/ d
PCHD rev O1/16/02