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A32 146
� r � • `��.y� . ` Site Evalu�tion Application � 2P�1 . , � t` , Date. � - � � v Fee Collected Y�S h0 . d t o� • °° /` r � A� 4. �-'1'4 APPLICATT_ON FOR IHPROVEMENTS PERHIT l�" � �� i� i • !���t�iit �e:��e:':c'�. �' . 'f-i,�t�����?Lv�:',nr_�".Ft� GW7ieZ .� ��'/��� i , . (� L'.: i ' : i'' ! ::�1Cirl�..,. � �i� ( `�_I��:l:_ � '� /i�: ,-s.� /%�.�i�� �-'. (�. T3cr„e Pt:one ;�: �!,=�'- �y;:: ;,� ^-�_�us�ness Ftio e ��: • 2. Name and address !� g¢3 Bo.sfon �d current owner: 3. ;Property Descriptioni � Lot size: ��y-ox, a QCr� `f' .JU/`l>��) G � /'�� i / I z:' 4. Tax map ��: �3�-7 Township: �615/1y� �or� Subdivision Name: _ - - Lot ��: 5. Directions to property:. State Road �� & Road Names, etc. �0 O�c'�" trurzL� �i1�S �� 7�iLl��-'inS t�ias: S7�O�Gt ���"�DY� r7'Q,t�r�%n5, on i2 -� [��t� .Se��v �na%� box4s 132/ on ��� md:! b��v�p� bur�� < l,e� � CrQad. p�pc.) : ri � ,., � - - -- - - - - �/ woo�n. . hou� (n„ I e�t ) - . 6.'_Permit requested for: New Installationc /1 Repair: ` - Additional Renovation re-using present system: 7. -Number of occupants or people to be served: � - - 8. Dimensions of Proposed Structures Widtli:_ - Dep�h: - 9. � What type (if any) additions, expansions, or replacement is anticipated to the struc- ture or facility that this sewage disposal system is intended to serve? - 10. Water �upply private? �_ public? community? spring? - - _ - _ -0ther-source?-(Specify): - �- - _ Are there any wells on adjoining property? If so,=identify location: _ - _ f .1. -- P d, �`� - Existin - - � . _ - . H w u � w �- 11,_ Type of structure or aci ity.. ropose . g• _ _ r. - Type.of-dwelling: House: -- Mobile Home; � Business_: -= o - - ,� : - `Type.of "business - - - _ - - ° - - - ` - - Number of Employees; " _ - _ -- -Number �f bedrooms: " Garbage Disposal?- Yes_ -No _•� __ '�- - Basement?- Yes = No �f so-, number of basement fixtuzes: `-' _ - 12.. Clearly stake all corners of the_property.and the co�rners of all proposed structures.- � ,I hereby make application to the Person County Health Department for_ a site --evaluation o� existing sy_stem;evaluation for-the on-site-sewage disposal�system £or _ the above!-described property: I.agree that the'contents.of th�s application.aze"tru� and�repres_ent the maximum facilities to be placed on the property._ I understand if = `the_site is altered or ttie intended use changes, the permit shall.become invalid. �Permits are valid for 60:months from date of issue. Permission is hereby granted to - � : enter- the :property -for. -the evaluation. .:G:S. 130A- 35(F) - - � . . = - . � ,�j� ' . S' ed 0 ner or Authorizeci l+gent ' ., .� , . . , � , , � , � . . � ' �. . . , . . .�i i , . i �� �. . . ' .� � � � � ' - , " .` . . . �IM7QyA 0 f�JfEt� • . . . � � . . - F� � • 4�. �I \ �,,.� . , � �. . . , � , . � . , � . � . . . . . ,. •; . , . . . ... .. � � r . ''y, ,),� ► �,/'� � ... � � �,�-� j--/� f t�yYt�}ii s�ndza uo�ss�wwo� �(�y : :.:.,_'�•�'�'- �^,. � ,.�•:ti � �, , , '.i � ;, � � � ,:;,., tic;o�),,�t � _,�r-.�'.`�,'� �` � � ' �1..� ' �. ; � � , , , . � , - - � ��v-�, �iJ;'Y---:�61 l�`;� �{' � �: � . :-��'�'� �� % \ ; ^' 4 � `\ i � , � %,C� , � � ,� , 1 7''� faa���As/�ns. pu;: c�l ll';l'Y�� �l`�'*'';.� `' '� = d' � ..;.,) 1 ,..:;: .�,,.f. �' . � . � � �.� ,;,,� �- .L�' ��L � �,.Y �o Ac�._.�^ S^N� �•,. ���:\y ^ :• ,a`' � ♦ ��' \. "� � .•� �7►— .�1j" S • � \ 6L:t_� '''-� • �� � � � '� �� / �; '�y �rft �!::C`[' )' '�i�� � :. ��':/ J'! / � o.11:.q7 '�'• ,ti. ! i \ F �� �r �_��1 � � ..r vr �� �, � � Q�Zt � Of�� , f J J0J13 21�� �..�, � il e? "d � I�Q .�,1[:1C�J1Ci /���1:!'� i �jal: .;'� , ��"� � • i 4 �-''� ' 4, �. 8LF/' ` o �//. �1d 't�L6✓ �a'9cua�so/� � � � . ; � � � � ' ►v �i � � ' F� • : ��.� ..-�.:e::. ,;� S7�J /I H!' � 1 en �� ue w_�� �• ,n •�• c.e� s�, uo;s�,vac �'�, � ��lI�ON �:��no'Jt�s'�ed ,.d�.+l ��o.�,{�n9 uo���a��p /.w ��p„n :-ti1 �11;�a� 'peH 'f d�;t!iia• i fr�.�, ,�.,-:v'� t�,� ��1 .. :,-...�::. , , U/�QJD� - _ � ... . • , '�.. ; r � �,,,,,.,,,.:,_.,..,`.._.., — ---' � �. , s1 •cu , b�.��f�,�.1 �7.� ��t�l�l . . � .. � �r ct-rs -t� - � � . , '� �o � ,� ,�p;PCt�r \ , , . , � , � �O ' ��.f�0.fF1 , . � , . �.� j, : rt •�rz • � , , , , \ . � ^��/: • 9z •oes � d � ,�i,a�,ot•v , �,�., , , � ,, , .«•U01 . ' f `i'/ / , . � � . j�4p•S . . : ' -/ , � . , , , , � � „ ,� , , � M'� \ !. , \f� .. /' /.%��' 2i ' �p . aY �1 �1ae scnxray .�auio�y� ;N , � : , i �1'� X � ,. . ; ; � , ' �. � ./r bE et?� �'� + Q i , � � , papoc�r , i /' �,c+do ' �, a• *' ��'' � � � /ts uiG u0ii + , �, , f9 �'. ' y a /, , � �+' � r�98 uwd uay 6u�/s�xa / ( , � � .�rz� + / f ~ . ` / � �r "1 O/10937 �. , . . , ��,�� � �'° , ,!. ..�.� � � � . sa���,. L69'9/ �, P_ ��. . � , , ,i� ,�. . , r , , � � � � r�� Y�' � N o /' � . . , ,, . / �� � �� � �, � ' . ' ; . ��� . o� � �� s ' ' �'•'2 '=`.: "� /' �� „ � � � � � . „ Wd0 • 1 ,i , , � � � � . � � �, �, � , �_ � � � � 1 �d �x�r; �+a�� � ' � : • _� . ,. –� � � � �` � � _ �i !' � � , ,, . , , , „ �, , ��/I _ �` / , ��.. � �, ts•i�s=� :. ,<'� \�, , , 0� � �. � � � .(�i � / . ., is tss� • d� , :L ;�j , . , � �. � ,. � / /�� .�,�� .►l.OFeA.'�P �' \_t' . . ' . � . . , , � . . i.�l i � . . � � � F?•� s , ;. . :,'�-, ►6 N � --�� Loo� b�+m5 � '., 3-:v ��•� �� d,1��C'm s �,,� ' ,��f07f d�� .��/ , ��9 � � ."L......� t � � n� .� • , , � � , �1 ,. , � ��� �,/p1� , _ ... 1 , . . , � , � � , � � � I' ... .. ,. � , � � • I i + � , r � ' ,� J I f PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Tax Map # � .� �- Parcel # 1 �f- �a n .�' A� Zoning Township Clwrier/C'nntractnr /L/���_ � �D�a.��,�,... �/��- 0 � DateJ- � S � �s .�c�s _�.1�D'�'�.�.-��_� �-� Subdivision Name Lot# / 8.w, 1 ^' N' �� Layout l��/� ��� �'�.`."-^�,-o-�� '�-� �j,,,�,,.,�� �� .zeG . ,_— ;,�I.v.¢-P.Q 10'�"'" fZe�+� �� ot � s.R.# !! i 3 As Installed SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area a. �-s Size of Tank "/6zs-a- SFD Y Mobile Home j/ Size of Pump Tank N/�4 Business # of Bedrooms�_ Nitrification Line 4�� d�� f 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 change� Well and Septic Layout by�.� ,!� �'�� �-o-c � Comments: Installed by =i, L�°+a g Approved by. Well Permit Paid WELL SYSTEM SPECIFICATIONS Individual V Semi-Public Required Slab Public Replacement Air Vent �(w. ct�) Site Approved_� Required Well Log ✓ Well Head Approved�/� w� u�� Well Tag ✓ Grouting Approved ✓ Comments: Date 9� a�- �%s Instal led by t��-v�,.� �l� �o . Approved by I.�r1. ���`-�'^-� 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 applicaeon. Neither Person Counry nor the environmental health specialist wa�rants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:\amipro\permitsam 01/95 rev.1.0 a . • . i .� /. Date: �i31�7� ' Owner: �i% % � r �.�- Location/Directio s: — PrRSON COUNTY �NVI:RONM�NTAL HL•'ALTH WELL LOG � SR# /��.� . �::�'''.vision N�ll»C: �.� �%`n.� L �:� ;,0 1��. LOC ## Drilling Contractor: _� ��, � t��� �/ �,�; I/:��,� � ���� WELL CONSTRUC'�'ION Distance from Ncarest Pro�x:rry Liiic /s �h•� llistancc from Source of Pollution J � d ;�1 �- S Total Dep.th: ' Ft. Yicld: �1 GPM Static VYa[er Level Ft. Water Bearing Zones: Depth ��Ft.�_Ft. Ft. �t. Casing: Depth: From �to��Ft. Diameter: �� Inches TYPE: Stcel � Galvanized Steel . i If Steel, does owner approve: Yes No � Weight: l,� Thickness: 1 R'�, Height Above Ground: ��, Inches Drive Shoe: Yes_��No ' i Were Froblems Encountercd in Setting the Casing? Yes No .� � rr • .tt 'yes" give reason: Grout: Type: Neat Sand/Cement � Concrete � Annular Space Width 3 Inches Water in Annular Spacc: Yes No � Method: Pumped Pressure Poured ✓ Dep��: Fr�m� p to a-o rt. , Materials Used: No. Bags Portland Cement �- Weight of .1 bag��lbs. If mixture (sand, gravcl, cuttinbs) - Ratio: �_ to � ID Plates: Yes ✓ No � � � 4 x 4 slab Yes_D� No I HEREBY CERTIFY THAT THE A.BOVE 1NFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS �SET FORTH BY�THE PERSON COUNZ'X �-IEALTH DEPAR'T'MENT. ��� � -�%-�-�_ � � � ��[ S.S� Si�nature of (_'ontractor Datc d �