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Pers o n3 D ep.�
APPi,ICATION FOR SERVICE
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Permit requested by: . � Dimensions or Pro osed Structure:
ner/prospective owner/agent:�,�' �sr 1� lelc� 1� Width: �4 x G�o
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v . Home Phone #: �9-1-3y p�
� usiness Phone #: S�q -�.la 1 cx+ 183
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ame and address of
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?
11Dn�. -
owner: 9. Water s pply type:
private public ❑ community �- spri`n,�g -
Are any wells on adjoining property?YesVJ No �j.
If so, identify location:
Descrintion: Lot size: �f
Tax Map#:
Parcel#: _
Township:.
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�. Directions to property: State Road #& Road
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i. Number of occupants or people to be served: �_
0. Type of structure/facility: Proposed: C�Existing: Q
Type of dwelling:
House: ❑ Mobile Home: �Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: 3
Garbage Disposal? Yes ❑ No C'
�Basement? Yes ❑ No�7 If so, # of basement �xtures:
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 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 after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
Signec� Owner or Authorized Agent
Permit Issued C�d'�
Permit Denied ❑
Plat Observed ❑
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Signature �G�+�1 Date
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< , FACI'9RS-5TfEEVALUR7IOPF ':; ,.;:. .. i ..XRES't AREA2 ..:::' ': AREA3::' ARE�d
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1. SIAPE(%) S S S S
u 3-S`�jo u u u
2. SOIL7FJC7lJRE(12-361N.) ��� S S S
(SANDY, LOAMY. CLAYEY. NOTE 2:1 CL.AY) P PS PS PS
U'— U U U
3. S01L S77tUCIVRE (12•36IN.) S S S
(MYEYS0ILS) S' s'� � PS PS PS
U U U
3. SOIL DEPiF1(RiJ �:= '` S S S
PS ���� PS PS PS
�(„'� U U U
S. RESTRICi1VEHORIZONS(IN.) S' S S S
(IINPERVIOUS S7TtATA. ROCK) S � � � PS PS PS
U ��`�� U U U
6. SOiLDRAINAGFIGROUNDWATER S i� S S
(FJC[ERNAL R iN7ERNAL) S� U ��L PS PS
U U U U
�. son rexMEna��.rrv s s s s _
(PERCO[AA710N RA7'E) � S U�R� PS PS PS
U U U
8. AVAIIABI.ESPACE S S S S
U �p PS PS PS
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9. STCECLASSiFICATION(SEEBELOW) � �
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SO1L SEAiES
SSUITADLE PS-PROVISIONALLYSUITA6LE U-UNSUITABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope pattems, etC.� C:VIMIPRO�DOCSU�PPSEC.SM FWANCE.PC
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT PERNIIT
Not for wasa� water system construction. No permit(sl for Construction Location or
Relocation �ctivity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # .Q �� Parcel # �y%
Zoning Township �vs�� y �o.zr � " "
Owner/Contractor �E�,ss,c� ,� . t,�PEL�,c� Date � _7� _ p�
Location/Address yg_� -�y �.c/ ,
tc�r is o.✓ .t�/4s�T /�� Mic� S) S.R.# ///�
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area /,3,; A� Size of Tank /�oo t�A�.
SFD Mobile Home ✓ Size of Pump Tank �Cl/r�
Business # of Bedrooms .3 Nitrification Line yoo % X3 �
Max Depth Trenches za"- zy "
Permits may be voided if site is altered or intended use.�
Well and Septic Layout by �� � �,���
Comments: 90 � - �u ��
Date �'-1� - 9� Installed by It, fe�,en1'ET� C Approved by.
ell Permit Paid
�iividual ✓
WELL SYSTEM SPECIFICATIONS
Semi-Public.
Replacement
Site Approved [/
Well Head Approved /
Grouting Approved
Comments:
Required Slab v
Air Vent
Required Well Log/
Well Tag �/
Date �' /��' Installed by /{. (3A2r,.,�?`7�' Approved by
t �au V � � 1
T�
This report is based in part on information provided the homeowner or his�er
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 remain potable.
c:lamipro\permit.sam O1/95 rev.l.l
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Sg9� p? 307.26 TOTAL
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PERSON COUNTY ENVIRONMENTAL HEhLTH
WELL LOG
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Date: ?/�/ Yt�'
Owner: �'! e ! ; .�a � !.t/� /C � � SR# // /
Location/Directions: �! 9 S. r/� ��� c��T1 �� �.d�V R� d �
G a7" �` � .�. T � � •
Subdivision �N�un . � Lot #
Drilling Contractor: �c�'i�� � 4r n �Tr�
WELt, CONSTRUCI'ION
Distance from Nearest Properry Line Distance from Source of
Pollution
Total.Dep.th:� /d o' Ft. Yield: l GPM Static Water Level 2 S Ft.
Water Bearing Zones: Depth �S Ft. F� F� �t.
Casing: Depth: From b to 3 Y Ft. Diameter: 6 ly Inches
TYPE: Steel � Galvanized Steel 1�^
If Steel, does owner approve: Y�s No
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� Weight: � Thic s. Height Above Ground: �� Inches
I?rive Shoe: Yes_�k�No '�� . .
Were Problems Encountered in Setting the Casing? Yes No,�
If "yes" give reason:
Grout: Type: Neat Sand/Cement 2� Coricrete
Annular. Space Width Inches
Water in Annular Space: Yes No
. _ .. Method: Pumped - - Pr:ssure � Poured � - - . � - - = -
Depth: From o to 2 o Ft. . .
Materials Used: No. Bags Portland Cement Weight of .l bag__lbs.
If mixture (sand, grayel; cuttings) - Ratio: to
ID Plates: Yes'°� ' No � � �
� 4 x 4 slab Yes�—No
9
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON COUi1"I'Y HEALTH DEPARTMENT.
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iQnat'uie of Contractor Datc
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