A32 145Prmount paid ���•
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ion of Existing System (Loan Closing)
Permit for New Well
Renlace Existing Well
Dimensions or Proposed Stcucture:
dth: ,_�
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'
,,i�.►:..
9. Water supply type:
private f� . public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes (�. No Q.
; If so, identify location: .� E� 7��' °�- —
10. Type of structurelfacility: Proposed: [�Existing�
Type of dwelling:
House: Ll Mobile Home: � Business: ❑
Type of business:
INumber of Employees:���_ �r%
Number of bedrooms:
Garbage Disposal? Yes ❑ No� '��`
Basement? Yes❑ No� If so, # of basement fixt�
d. 1�lUIIIDGI Vl V�.�.urauw vs t.�.�.i-'- -- -- --- —
CLEARLY STAKE ALL CORI�IERS OF THE PROPEU T�Y�ANU THE CORI�IERS OF
PROPOSED STRUCT
I hereby make application to the Pet'SOn COunt� Health Depat'tment for a site evaluation for the o
sewage disposat system for the above described property• I agree thatune� �iand if the site Psaltered or the
and represent the maximum facilities to be placed on the property. I
intended use changes, the permit shall become invalid. I understand that be�erstand hat in the event ha�
issued, I must present a survey plat of the property to the Health Dept. I un
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluatio�
the site by the Health Dept., this application shall become void and all fees paid forfeited.
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Si�nc� Owner or Authorized Agent
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B 2525
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT 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 # � � 4� Parcel # � / �
Zoning Township i,�!�h .� �
Owner/Contractor n n�1 i � �� Date -�i'�
Location/Address � �'' � � �t,�'''°'^ �nn � � �� �r' T/, �A n I._ ..��► ,,,, �
Subdivision Name
Lot#
S.R.#
SEWAGE SYSTEM SPECIFICATIONS
Lot Area ����{'�'[' Size of Tank ��
Mobile Home t/ Size of Pump Tank
;ss # of Bedrooms�_ Nitrification Line
Max Depth Trenches�
� . (� �1�C.�-.
Permits may be voided if site
Well and Septic L�a�yqut by,�
use
Date 1{-S- 99 Installed by %Cv//,'c Approved by.
�/�L�i N7' i.¢�� � �Q.vkJ � �h"%7 �.
Well Permit Paid ❑ V,�ELL SYSTEM SPECIFICATIONS
Individual emi-Public Required Slab
Public Replacement Air Vent
Site A roved Required Well og �'
Well ead Appr ed ellC�ag
_ . . . �
Installed by
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 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 conti�ue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
Q l�
wtthln the Qreo o{ a' '
thot regu�ates pa�cels nJ 83•15
° ult t �� rr�unic(pality 36,080,E
parcols of land;
Parcela of land and �•
an existing street; �"'
r other structure, �
or `^ �
the recombinctlon �~ O
other exception to � �
auch thot the �
lie best of the eunrey�r'� ('�`'+
�Q) through (d) Qbove. V
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. !2_ Ip _98 �j � / •�
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N 83�15����E
103.45
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84'S5'37'E
117.18 �
�� 249,51 163.43 .ot ,:� .�
51.73 ; t���� ,'
��NTRO ORNE `
3 � C R r� 1� '` t;
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� �~ PROPOSED 50' EASEMENT � � .�x K ;.
�i �L o t � � 4 .
� °� 146.19 �., <.
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r-� S 83°15'00'W �� ;
PR���SEU Sp� E4S �
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EMENT
Wi N 82•39'35 t✓ 5�.5.3
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D.B. � . nice � ',.
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'.withln`;the arec of Q `
;that,regutot
ount,Y+ �s Parcela r N 83'IS'OQi
s9u1qte'� municipallty 36,08 E
parcols o( IQ�d;
r Parcel� of lo�d and �•
an ex(�ting atreet; �—
or other atructure, �
t or.�. �
.; ..•,,�,.; �
: the`recomb(natlon � O
other.except�o� to .`
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euch''{hat fhe �
:he beat oi the eurveyor'� r�, w
�Q) through (d) Qbova V O
. Iz._ �p _98 ?� � � •�'
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3CUNrRO� CORNER 51.73 r
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� ��; PROPOSED 50' EASEMENT � �
� � 146.19 �'
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� S 83'15'00'W
PR���S�U 5p, EAS
� _ � 52 9� EMENT
�V 8�,39�35 �
Wl��in�., �I ,- , _� ��•rZ
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Sudie B, & � �rni<
D.B. � �_r
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PERSON COUNTY HEALTH DEPARTMENT
SUBSURFACE WASTEWATER SYSTENi 1VIOIVITORING REPORT
-�-r � tY5
Date �f Inspec i�n System Installation Date Tyre Tax Map Parcel #
Property Address
Instructions: Check yes or no for appropriate items and explain inspace provided for remarks an�
comments. If an itsm is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate
by "N" and explain. Nate that this monitoring form is not totally inclusive for all systems. All maintenance
and monitoring items specifisd in the permit are to be carried out.
INSPECTION RE�ULTS
�OLLECTION SYSTEM�
Evidence of leaks ?
Tank risers accessible, free of
infiltration and surface water diverted ?
5eptic tank needs pumping ?
Inches of solids:
Septic tank filter cleaned ?
FFFLUENT DOSING 3YSTEM:
Required pumps present & functional ?
High water alarm operating properly 7
Floats, vatves, etc. in good condition ?
Cantrol panel & components in good
condition 7
Eff;uent free of excess solids 7
Inches of solids(pump/dose tac�):
Elapsed time raadings ?
Counter readings ?
Drawdown rate:
YES / N�
❑ / ❑
■ ■
■ ■
❑ 1 ❑
❑ � L7
0 � ❑
❑ � ❑
❑ � ❑
DISPOSAL FIELD:
Evidence of effiuent surfacing ? ❑
Evidence of effTuent ponding in trenches ?❑
Surface water effectively diverted ? ❑
Di���ISIQRS/S'N2ICS �rO�Slly anain±ained ? ❑
Vegetative cover maintained ? ❑
Protected from trafiic/unauthorized uses ? ❑
Distribution devices in good coadition ?❑
Field free of settIed or Iow areas ? ❑
/
/
/
/
/
/
/
�
■
■
■
■
PRESSURE DISTRIBUTION SYSTENI:
Tumups/cleanouts/vatves/taps intact &
accessible ? ❑� � ❑
Pressnre head properly adjusted ? ❑ � ❑
COVIPLIANCE:
Compliant
Non-compliant
Needs Mzinter.ance
�����o��
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REMARKS
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