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* PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERNIIT
Tax Map # �.�� Parcel # /C9'�
�oning Township �
Owner/Contractor��,-,.�c�s �' /� �/�/'rl f� �� 11.'r,�� Date %� G � �/��'
Location/Address f y�I Cr.l�%,'✓� t L.�D rC?�
S.R.#
Subdivision Name Lot#
%
SEWAGE SYSTEM SPECIFICATIONS
ea I Size o�Tank
Home Size o :Pum�
Perir�it Void er 60 r�ths�ermit Void if not in com�liance with
Pe ts may be voided if site is altered or intended use changed.
ell and Septic Layout by
Comments: _ _
Date
Installed by
Approved by
WELL SYSTEM SPECIFICATIONS
Individual_��Semi-Public Required Slab
Public Replacement �/ Air Vent
Site Approved Required Well Lo�
Well Head Approved Well ag
Grouting Approved� f�� ,� � I� _ -
Comments:
Date Installed by
� (I�1�,�.-� .�.I.l�,w� CP,C.�`�-i
Approved by
Tltis report is ba_ced in part on infonnation provided the homeowner or his/her representative in the application submitted for this pemut The
environmental health specialist is not responsible for false or misleading information contained in the application The environmental health specialist
is also not responsibte for concealed conditions on the propetty or for statements in this report that may have resulted from false or misleading
statements provided to him in the application Neithet Petson County not the environmental health specialist wazrants that the septic tatilc system will
continue to function satisfadorily in the future or that the water supply will remain potable. c:�amipro�permitsam O1/95 rev.1.0
ORIGINAL
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Y1.iRSON COIIN'I'Y I:NVl:1ZONP;:;N'I'l�L, I1JiAL�II
Date:� =� �_ '
_ Owner: �
-�I. _/. �_,�-�,� S
Location/Direc[ions: _,1�.�-� �%',_�,, S
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�u���vasion N�urie: _ _..._.____ '
----- _....... __ Lot #
Drillin Contractor::� , _ __ _._._..... _-.--_---- ..______ .
� . . _J �-�- �=-- . _ _�._tl �----- _� .,
WFI.I. C�ONS;I'RIICT'[ON � -�;�i
Distance from Nearest Pro��criy Lin��.__I.�����,,,5 llist,incc .from Source of ' -'.'`�:�'`�
Pollution � . :.a
Total �Depth: Fr. Yi�l�i:_ _��._--- �'�'M Static Water Level .F =;':i
Water B�earing Lones: Dep�h ---___- Ilt. �' �'.�
' �=t.
Cas�ing: Dept}i: � From ic� �- -__. .___.._ Ft. ��t. .
__.._. I��. lliamc�cr: � � '
� Inches ;i
TYPE: Steel � __ G,ilv;ini�ccl Stecl � . . `,;� .
X.� Stecl, does owncr approv�;: Yc:; No . ''-'
' Weighc:�_'rhicicncss:-- ,__/ ;�_b�'Ieight Above Ground: 1--- _ ���
Driv e S ho e: Xes �/N �- ---. . . . • •--,L-.-- �ches = .�
Werc Problems E�icountcrccl ii�i Scttiii� Lhc C;,sin`�? Xcs ' No "� ��
Zf � yes glve rcason: �.
Grout: .Type: Neat , � : �:����:�a
S:�,icl/Cc�i�ent Coricre[e ''-':'�
A.nnular.�Spacc Wi�lt��___,�_� _-----�,ic}lcs � , . �����J`'•
1�Yater in Annular Spacc: Y�s No � � �'
Metho.d:' Purn�x:c�--...-- ---1'rc:,tiur�: 1'c�urccl � . . . � � . ;,•,�:;
Dcpth: rrom__12__- --- t��.-_��_ ---- I:` - __. ��;i
Materials Userl: No. I3a�� 1'ort.(�u►d Ccmcnt 1'``' �
If miu,ture . —.--_.__ Wei�t of .1�bag�lbs:M�
(sand, gravcl; cutt�r���ti lZatio: ;,`.�""}�..
„ ) - �—to .;,��
�ID Plates: Ycs ..i No _ . , � : . .. � ,;;::�
----.-._.. . ',::��
� 4 x 4 slab Yes _��to_..__..__.:_ , - � • ... ���a
_._�_._...-----I�RI l,,I .f NC� I .CX� :,.:,
]�e tll - - -. __----- -
Fram To
Fi�rrnation Desctiption
s)_.J�_t!l _ �v�.s'�� .L
, _ - ----_. __ _ _�--- ._. • �
I HEREBX CERTIFY THAT TI-IE A]30VC 1NFORMATION IS CORRECT
. T�S WELL WAS CONSTRUCTE�� iN ACCORDANCE WITI-� REGULATTONS'H
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FORTH BY��'H� P�RSON CnUN�'1' I-II;AI_,TI-I DEPAI:TMEN"I'. � '
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