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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT
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 #_��'oZ Parcel # / � �
Zoning Township 5 h r
Owner/Contractor � � , � - � �
Location/Address -}�,c rd p�'vt i I 1 S
�c�`s �-��te IS dri� e o
Subdivision Name
ate � �?l0 9
Rax bo ro T�R c�+ NawK� n s
S.R.# l l l 3
Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area l• aD �9c �P Size of Tank Ob
SFD ✓ Mobile Home Size of Pump Tank_ �i r9
Business # of Bedrooms 3 Nitrification Line a L%nes o`�'SG1 X�'
Max Depth Trenches a(n � r�•
Permits may be voided if site is
Well and Septic Layout by
Comments:
Date Installed by �� Pw� 5 Approved by -�Y%
Well Permit Paid WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab �
Public Replace ent Air Vent L�
Site Approved � Required Well Log ✓
Well Head Approved Well Tag ✓
Grouting Approved �
Comments:
Date
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 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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_ Bacteria � _ Chemical � _ Petroleum � _ Pesticide � _ Lead
Permit requested by:
ner/prospective owner/agent: � �
dress: /U�71� /1;�r//� �7// /Z�
/�..-,-/,� /7// �/vl�J��%/
ome Phone #: 3�� f z3�/%
usiness Phone #: -���/''��
Name and address of current owner:
. Lot size: � � �- •
. Dimensions or Proposed Structure:
What type (if any, additions, expansions, or
�lacement is anticipated to the structure or facility
t this sewage disposal system is intended to serve?
9. Water supply type:
private C�public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No C�
If so, identify location:
. Tax Map#: 32 `►'� �e 10. Type of structure/facility: Proposed: ❑Existing: ❑
Parcel#: � � C ���— Type of dwelling:
Township: �n �ar House: B�Iobile Home: ❑ Business: ❑
� -Fr Type of business:
n, 5. Directions to property: State Road #& Road
¢ Number of Employees:
z ames, etc.
�.�� �, �� � ��, ��/ Number of bedrooms: 3
� Garba e Dis osal? Yes ❑ No l�
d ct i �,� �- 'ti-,-s S L,-� g P
F' Basement? Yes ❑ No �f so, # of basement fixtures:
z
Number of occupants or people to be served: �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Person County Health Department 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 applic�on shall become void and all fees paid forfeited.
Signed Owner or Authorized Agent
,
Permit Issued L�'
Permit Denied ❑
Plat Observed ❑
, �Signature � Date
RECOMMENDATIONS/COMMENTS:
•� � �D
STTE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.� C:WNIPRO�DOCSIAPPSEC.SM FINANCE.PC
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Jur_z7_g6 08:46A PERSON COl)NTY HEALTN
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p1;RS4N COU?JT1' FNVC RONMf'!�TAL Hi•,ALTH
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�wner: _ _� _ __.. SFZ�� �rr.3 _
Location/Dir ctions: Y��� � �.�P�..�a �� /����� �.s
��.�, �s� �, �� . -- __._ .
Su?�di��i��i�;� Natn�� , .� �. �—. � ' �Lut �r �._ � _
IJrilling ConUr�ctar: `�� - ,�_��.�� — i�� .! _ � _ ._
,W,�,��, CQN$TR��.CTInN
DiStsnCe fr�sll Ncaic��t Pr�p`-ty Linc 1� _ pitcanc:c i'r��,ii Sourcc of
I'ollution „�o �
Total D�'p.th:_ / As' Ft, Yie1d: /�" GPM Static Water L�evel za Ft.
Water Bcaring'Loncs: Depth �d Ft. i__ d �___Ft. F�. Ft.
C:s�su�►�: Dcpth: From.�,,..�io� Ft. I�iametcr:��,�Islches
TYPE: Stcel Gs�lvaziiieci Sceel ✓
if Stcel, docs ownct ap�rovc: Yes____.�_No
Weigh::�� 1�. Thickncss: / S 8 Hcig?�t Abc�ve Ground; l� I- -���cs
Drivc Shoc: Ycs �/ No
WerE I'toblcros Encountcrai in Sctting �hc Casin�? Yes � N�� ___
if 'y�,s" g��►•� r;:�s�n:
Grout: Typc: Ncat ✓ __ ,S�tncl/Ccmc:nt� ✓ �C;oncrctc_
A,rmular Spacc Width � _lnches
Waier in Artnular Spacc: Ycs. , Na �/
Methoci; �uriFx:d � Prrssure �'ouru�_,-✓ �
ncpc�: Fr�m � to 02 0_ Fi.
,Muterials Used: No. Bags Portland Cemenc� Wcight of �
1F '
bs�_� hs.
mix�urc (sand, gravel, cucbngs) - Rat3o�__,� i, t�_
ID Platcs: Yes ✓ ,� No__._____ �
4 x� slnb Yes � No
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DRIL[,IN� I,OC
De th ~ ~ `—
From To Formation Descri�iion !!
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I H�REBY CERTiFYTHATTHEt1RUVEYNF(7KMA'TIC�N lS C(�KRL'•Cl' ANU'1'HA'!'
T��1S W�L�, WAS C(?NSTRUCTED TN ACCnRr).'LNt'E wt't'H Ft�C.�ULA't'1C)NS �ET
FORTH RY�TIIL PEEtSc�ti t.';':L'?�'I'�' HEALTN ULYf1R"rMEN'i.
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