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A32 136� Person County Health Department � Well Permit � Date:l /—ZC�'�//This Permit Void After 3'�ears '� Owner: Tar�'.s /� �5;� ��N �.-✓-- SR# / 1 f3 LOCBttOn/nirer.tinnc� /s �S �.� %�u��L � 1 %c,r��: �f7�s•�� /�3w k; .•r L •t; , � Se/aK_,; % /%: � Yi, �' /�%vh v.� 1.��°!-� Subdivision Name: ' Drilling Contracwr: _ WELL CONSTRUCTION ►� Distance from Nearest Property Line Distance from Source of ��,' Pollution ; �, Total Depth: Ft Yield: �_GPM Stadc Water L.evel Ft � Water Beating Zones: Dep� ��c,,4_ FG Ft. t. Casing: Depth: From l`] to �(L Ft Diameter Inches TYPE: Sceel Galvanized Steel If Steel, does owner approve: 7 No Weight: Thiclrness: Height Above Ground: Inches Drive Shce: Yes No Were Problems Encountered in Setting the Casing? Yes No If "yes" give reason: Grout: � Type: Neat S ement � Concrete Annular Space Width � Inches Water in Armulaz Space: Yes No Method: Pumped� Pre:�c�}r� Poured � Depth: Fmm to C..l�� Fc Materials Used: No. Bags Portland Cement Weight of 1 bag lbs. If mixture (sand, gra�cuttings) - Ratio: to ID Plates: Yes No 4 x 4 slab Yes �— No I HEREBY CERTTFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN CCORDANCE WITH RE ULATTONS SET FORTH BY THE PERSON COUNTY AR NT• Z �Z Q Signanae of Contractor Due � ;� c�� l/ -2G-91 ;. Sanitarians Sign re Date Issued Sanitarians Signature Date Completed Sketch well location on reverse side. , / '. .: NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water supplies, etc. Note special problems existing on lot. Writz in measurements in order that instaliations may be located at later date. Note location of water supplies on adjacent lots. (1) (z) ■■■■■■■■■■■■� ��..■■■■■.■■■.■ �:::��s��. ��s�■��■ ...��s�r� �� c_.��o�■_•��; ��N��■ ��o��r�.�� ==a��■��■ ■�■��■ ■��t��:�:�� ■�� r��ii/!!� ��■�� //.%��►�/�ii��, �� r��■■►� ��■■■■■�� n�■ i:::��:��::�� ■■ � h O a d ��,.. ° 6 . . � � � � � � q 6.�'1 C�-.e �e�p�- Improvements Permit (Established/Recorded Lot) Improvements Pernut (Unrecorded Lot) Improvements Permit (Mobile Home Replace) mprovements Permit (Addition) . � . � -,�-�� . Reinspection of Existing System (Loan Closing) _ Repair/Replace existing Septic System Permit for New Well _ Replace Existing Well 1. Permit requested by: 7. Dimensions or Proposed Structure: owner/prospective owner/agent: �►uv �� Width: �� dec� ro d'�'' S, ddress: q'`J. 4 F��Kc�v� LcbP �. Depth: /� ' C� �ea`i�ao�• �- b a`µ-- � G• Z�'�� 8. What type (if any, additions, expansions, or � replacement is anticipated to the structure or facility w that this sewage disposal system is intended to serve? U ome Phone #: �C�y -''�O'-�Z � usiness Phone #: �d 3 - �078 - a 2. Name and address of current owner: 9. Water �s Jy type: E private l�J pu�lic ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No ❑ If so, identify location: 3. Property Description: Lot size: � C- . Tax Map#: � 3 a 10. Type of structure/facility: Proposed: �Existing: ❑ Parcel#: 13 �o Type of dwelling: Township: uS1-� a r House: ❑ Mobile Home: ❑ Business: ❑ � Type of business: n, 5. Directions to property: State Road #& Road ¢ Number of Employees: � ames, etc. Number of bedrooms: �_ �¢ Garbage Disposal? Yes ❑ No ❑ �'' Basement? Yes ❑ No ❑ If so, # of basement fixtures: I6. Number of occupants or people to be served: CLEARLY STAKE ALL CORNERS OF THE PROPERTY ANll '1'ti� (:UKlv�l� vr ALL PROPOSED STRUCTURES. I hereby make application to the Pet'son County Health Depat'tment 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. Signed Owner or uthorized Agent Permit Issued ❑ Permit Denied ❑ Plat Observed ❑ Signature . � • . •. � . Da�e , fl+C7'ORS-$TfE EVALiiA770N f�RPA l AREA 2::: AREA 3 ARFA d:::. _ _ .._._ _.. _ __ . _ ,,,:.. _ : 1. SLOPE (%) � S S S S � PS PS PS PS � U U U U 2. SOIL TEXNRE (12-361N.) S S S � S (SANDY, LOAMY. CLAYEY, NOTE 2:1 CLAY) PS PS PS PS v u u u 3. SOIL STRUCNRE (12-361NJ S S S S (CLAYEY SOiLS) . PS PS PS PS U U U U 4. SOIL DEPTfi (IN.) � ' S S . S 5 PS PS PS PS U U U U 5. RESTRICI7VEHOR[ZONS(iN.) S S S S (IMPERVIOUS STRATA, ROCK) PS PS PS PS U U U U 6. SOIL DRAINAG&GROUNDWATER S S S S (EXTERNAL & INTERNAL) PS PS PS PS U U U U 7. SOIL. PERMEABILITY S S S S (PERCOLOATION RA7E) PS PS PS PS U U U U 8. AVAII.AHLESPACE S S S S PS PS PS PS U U U U 9. SITECLASSIFICAI'ION(SEEBELOVI� SOiI. SERIES SSUiTABLE PS-PROVISIONALLY SUITABLE U-UNSUITABLE RECOMMENDATIONS/COMMENTS: SITE CLASSIFTCATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope patterns, etc.� C:WM(PRO�DOCSIAPPSEC.SMFINANCE.PC ,� � _— � c � r � ( _'v � / r a� -"� 0890 PERSON COUNTY HEALT�I'DEPARTMENT --_ WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Tax Map # �i' 3'Z Parcel #/ 3� Zoning Township ��-� Owner/Contractor Ta%�..-,�� '� �� Date I- S— l 6 Location/Address � � � � �� '�-�... ` �� .R.# / / �,3 3ubdivision Name � Lot# 5EWAGE SYSTEM SPECIFICATIONS air Lot Area ��-� Size of Tank " � � > 1�(.�c �' Mobi,l �H,�me Size of Pump Tan • � iness # of Bedrooms�_ Nitrification Line ' Max Depth Trenches Permit Void after 60 months. Permit Void if not in compliance with zoning regulations. Permits may be voided if site is altered or intended use changed. Well and Septic Layout by ��f'� ��—*-�- �`,�� yy��-�'� n,,,,,,,,o„r�• �JYt�„� � ��.. `__ .7 6 0 � X � � G� Date Installed by ..� a„�.:� �'�;,� ..��t'1�' — ell v Site Ap ro� Well ad Grout'ng A ❑ WELL Semi-Publi Date Install'ed by pproved by TEM SPECIFI ATION5 Requir d Slab _ Air V nt W�'ll Tag Well Log L�l �,?do� K3) .� . This report is based in part on information provided the homeowner or his/her representative in the application submitted for this pertnit. 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 Counry 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 01/95 rev.1.0 ��V• 300' � R. LARRY RIMMER I D.8.137, P.299 1 I ' 'INEZ M. 0.8.16 C l �. . , - �. t �- , - �,�---`. __ . :�t .. _ " � __ _ y , � � _� ' �' :'�`:F = _ - . _ - - - PERSON COUNTY HEAL'I'H DEP�iRTME1�T _ - -�—_ � = - _ - _ -_.. � • _ , WELL AND SEWAGE STFE, LOCATION IMPROVEMENT PERMI'I' � ';� ; -� � - • _ .- � � , . - � Taic Map # Parcel # Township ' Zonin Date � 5��° � � . Owner/Contractor � ��. , . � "'� ` _�,,�. �. �� :�,�,,� {� � � H 1 Location/ S.R.# 5ubdivision Name Lot# Iayout � Q t4"'....— �� . �t�C't"iE �� ,�,y P� t�nu t.. c�c� �;Gr r • �:.{` �ti�G'Y_3� As Installed �y f��r+ -4 c D�-i tG�} '�Q F,c,�i+y jk�uSP C� .r l�� F f�. `�'r�. �� s� � r�►. , SEWAGE SYSTEM SPECIFICATIONS Lot Area Size of Tank_ �' ��'m� -'' Mobile Home _ Size of Pump Tank t # of Bedrooms � — Nitrification Line Max Depth Trenches Permit Void after 6Q months. Permit Void if not in compIiance with zoning regulations. Permits may be voided if site is alt red or ' nded use ,_ge ; Well and Septic Layout by Installed by, by, Well Permit Paid ❑ WELL SYSTEM SPECIFtCATIONS _="� Individual S ��-�ublic _- ' � � Required Siab-� - - Public eplacemen /` Air V�t� _ -� � � . / Site Approved � .� R�9iiired Weil Log.-� "`� Well Head proved Well Tag �-'"�! �� r' �'' Groutin � pprove � ' � Cor�a�nents: r �' �J � � � y/ f � - / � ; ate_ �� Installed'by %�� Approyedby ` � � ve in the �catian � foc �is p�� 'iUe This reQort is based in part on infotmation provided tbe homeow� a�a� �� .� �� y environmentul heaith specialist is noe respons�bie far false a �maiad� � � ��a � � � � � m� �� specialist is also not nespansible for concealcd eo[�tiot�s on �he P�J� misleading statements provided to hi�n in the applic�ian. Hdd� ��°Q CO°nh' �� t6�O�� p�gg � wnk system will continue to funcaon satisfactorily in the fum�e or thaEt6e water a►PP�Y a''b �n P°�' ��a°� .. . . . , . . . . , � AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (Void sixty (60) months from date of issuance) DATE: IlVIPROVEMENT PERNIIT #: .B d O 6 I TAX MAP #: PARCEL #: I3 ��OWNER'S REPRESENTATIVE: %�-y; , �, _ -� LOCATION/ADDRESS: . � � � � .. ,� � � r . �� C�, � j I � / i ��I%/1 'ti'" ,�a,. i i� _ � / � SUBDIVISION NAME: ��1� LOT #: SECTION OR BLOCK: AUTHORIZATION FOR CONSTRUCTION ISSUED BY: AUTHORIZATION CONDITIONS 1. The Wastewater system construction and installation must meet all of the conditions of the attached site plan and specifications as set forth in Improvements Permit #�D06 �. The construction and installation must also meet all applicable rules and laws. 2. No portion of the Wastewater system shall be covered or placed into use until inspected and approved by the Person County Health Department. 3. Any alterations in site or soil conditions (including structure locations) or modification in use, design wastewater flow, or wastewater characteristics as specified in the associated improvement permit and application, may void this authorization and associated permits. � 2-�-Yt�c%9G 6 �� 2��c-v ` � _sz ��uv`-6 . 4. Cond� � � � � r � � �� . � � �,� � _ _.�� .� . � � i �,/�� .i � _ � , � / � � � i �I' t� �/ - - - Person Requesting: � �