A31 76oQ
A:�ount paid �`�G �
. Receipt 0 ' a,0 �
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• ni r Lat.r� i avi
2 �c.s � �� � .. i .+.i+�� s.a.� k K ni �� °•:::r�`t�i'i`�• -i 'a� "�%�'
..i. t �� s ��' '....l..s:. �x�:i'�:� ��_�'�eEt:���eC�1CC$
Improvements Permit-(Established/Recorded Lot)
Imczrovements Permie (Unrecorded Lot)
lmpravements Permit (Mobile Home Replace)
Improvements Permit (Addition)
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9 � .. • ' .. '
Date
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_ Reinspection of Existing System (Loan Ctosing)
Repair/Replace existing Septic System
Petmit for New Wetl ^
_ �.5� t � ,v ,
_ Replace Existing WeII
. Permit requested by: . /��K�' . Dimensions or Proposed Structure:
o�vner/prospective owner/agent ' Width: �.�
Address: ` Depch: S�(a
- 8. What type (if any, additions, expansions, or
� repiacement is anticipated to lhe structure or tacility
w tha[ this sewage disposal system is in[ended to serve?
� Home Phone =;�3 � 3�0�— �f� �
a
usiness Phone n: 9l9 _���— OG 97
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2. Name and addre$s of current owne;: 9. Water suoply t}'pe:
� � pcivate Q. pubiic ❑ community ❑ spring Q
Are any wells cn adjoining property?Yes ❑ No (.�
If so, identify Iocation:�,�IJ -�Ro PF�tTY
3. Property Description: Lot size: _� �� —���� ��' ��S7ll�� .IIEC.i_ _
. Tax Mag�:�A.3. / 0:"Type of structurelfacility: Proposed: DExiscing: Q
Parceln: 7 C Type of dweIling:
Township: House: ❑ Mobile Home: �Business: CJ
5. Directions to property: State Road ;& Road Type of business:
ames,�tc. Number of Employees:
� � Number of bedrooms: 3
Garbage Disposal? Yes ❑ No �
B asement? Yes ❑ No �'If so, # of basement fixtures:
6. Number of occupants or people to be secved: ''�
CLEARLY STA%E ALL CORNERS OF THE PROPERTY AND THE CORNERS O�' ALL
PROPOSED STRUCTUR.ES.
I hereby make application to the Pet'son COunty ��Calth Department for a site evaluation for the on-site
sewage disposal system for the above desecibed property. I agree that ttie contents oi'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 Improvements Permit can be
issued, I must present a sucvey plat of the propecty to the Health Dept. I understand that in the event I have not
delivered a survey plac of the property to the Health Dept. within 60 DAYS after the date oE the evaluation of
the site by the Hcalth Dept., this application shall become void and all fees paid focfeited.
S�gne� Owner or Authonzed Agenl
. •' t V
' � 2937
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMI'ROVEMENT 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 # A 3� Parcel # 7�
Zoning Township v.s.�✓ or�
Owner/Contractor G�' .v %u. ��. Date S- � 7- �`�
Location/Address Gh 1' Lo.�; f� �? '�`� dn�����;y o� 1��,
a� ,--
�iC/. ��i0� �
Subdivision Name
Lot#
S.R.#
SEWAGE SYSTEM SPECIFICATIONS
� Lot Area ��(� � Ac . Size of Tank l UDD
Mobile Home `� Size of Pump Tank
;ss # of Bedrooms�_ Nitrification Line �%DO '!� 3'
- Max Depth Trenches �!)'�
Permits may be voided if site is
Well and Septic Layout by �.
Comments: S�c G'�,� �' %��
Date
ell
Approved,
Date
Installed by � CA
,
�')C%S �.tJ
� WELL SY�
Installed by.
or intended use changed.
I Air V
Well
Approved by,
A
i Slab
i Well Log _
Approved by.
This report is based in part on information provided the homeowner or 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 �nay 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:\amipro\permit.sam O1/95 rev.l.l
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AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: s/ 7- 9� Il1�'ROVF��NT PERtiII'T �: � 2937
TAX i�1P #: A 3 � PARCEL #: 7G
OWNER/OWNER'S REPRESENTATIVE: L�yN'��' � ��`'-
LOCATION/ADDRESS: ���
C�Q� /;< 1a�,s -
SUBDIVISION N��: "'
SECTION OR BLOCK:
AUTHORIZATION FOR CONSTRUCTION ISSUED BY:
�. ��-..�
AUTHORIZATION CONDITIONS
LOT m: �
1. The Wastewater system construction and 'mstallation must meet all of the conditions of the
attached site plan and specifications as set forth in Im�rovements Permit #.� Z�'37 . The
construction and installation must also meet all applicable rules and laws.
2. No portion of the Wastewater system shall be covered or plac..-d into use uaiil inspected and
approved by the Person County Heahh Departmeut.
3. Any akerations in site or soil conditions (including s�tructure locations) or modification in use,
design wastewater flow, or wastewater characteristics as spe�ified in the associated
improvement permit and application, may void this authorizaiion and associated permits.
4. Conditions: /'7�e � o�' % � �'v� ,Sep'!�� �¢you �`'
Schedule 40 solid �ine over dams Keep sevtic 100 feet from anv well 10 feet from anv
prooertv line 15 feet from basemeIIt wall S feet from anypart ofthe house. Keev well_at_
Ieast 25 feet from anv foundation and 10 feet from anv nropertv line -
Person Requesting:
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REFERENCES
D,B ; 152-534
D.B
• P,B, 18-116
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