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_ Improvements Permit (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing)
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rovements Permit (Unrecorded Lot)
Permit (Mobile Home Replace)
rovements Permit (Addition)
Repair/Replace existing Septic System
Permit for New Well
_, Replace Existing Well
.<.., ,:_ . .. _. _ _
Bacteria Chemical Petroleum ,_ Pesticide _._. Lead
1. Permit requested by: 7. Dimension or Proposed Structure:
owner/prospective owner/agent: Width: ` �
Address: .1�.� ��� S �1'� cC�, � Iv�� �• Depth: 7� �
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?
ome Phone #: G I r� - � � <C- � (a.�
usiness Phone #: ��o • 3 c.� - 7��./
, Name and address of cunent owner:
�j n�j t2
. Property Description: Lot size: �� X a-�
, Tax Map##: $ � � —
Parcel#: ) � `f
Township: ��� 'r'v r �
. Directions to property: State Road #& Road
ames, etc.
n.�
9. Water su,pply t}•pe:
private ��public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No Q
If so, identify location:
Number of occupants or people to be served: ,�_
10. Type of structurelfacility: Proposed: ClExisting: ❑
Type of dwelling:
House: ❑ Mobile Home: B'Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �
Garbage Disposal? Yes ❑ No ❑
Basement? Yes ❑ No � If so, # of basement fixtures:
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 application shall become void and all fees paid forfeited.
�-�j �. f �... _ ' ' _ A "�L.._:__.1 A _'_♦
permit Issued ❑ Signature
Permit Denied ❑
Plat Observed ❑
Date
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9. STTE MSSO-lCAT10N(SEE BELO�
SOIL SERIES
SSUITABLE PSPAOVISIOClAI.t.Y SllT[ABLE U-UNSUfCABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, propercy lines, roads, streams, gullies, wet areas, fill
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0.6. 160, P. 304
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224.12'
N81'40'14��W
ROBERT W. McCULLOUGH
D.B. 190, P. 459
(ORANGE C0.)
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MARK JOSEPH
D.B. 237
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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 # �Q ,3 Z Parcel # /(� y
Zoning Township �v�'/� Y /=a �K
Owner/Contractor /yq p!C i M G C �• �/ o v�; ti Date y-�v - q6
Location/Address ��,,� y/s7 S T/L o.�/ G� � ss ��
i/� onl �Ta�ii u�Avrc 1.^� D1Z/vc- --o.�/ LEr-1 S.R.# //'e'�y
ivision Name
LOt#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area /. � 7� L Size of Tank `x � s rint� /��o o CT•�t �
SFD Mobile Home ✓ Size of Pump Tank �/�
Business # of Bedrooms�_ Nitrification Line �x isri.v� 3�s ' x 3
Max Depth Trenches
Permits may be voided if site i altered or intended use cha ed.
Well and Septic Layout by �
Comments: �,eM�T ��� � rTc �/ �'v� .� t3c�iZo�;�9 �`7. /-1 _
� �� ,P,E��A-G�D �.lir%1 �_ d.�'_ M./�� �c/b cNa,��s-e ia Sc �i �c
Date Installed by Approved by `s �'��,
ell Permit�Paid C� WEL� SYST�M SPE�IFICAT�QNS
ell
�
Verit Y �—_�
e11 Log
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
H 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:lamipro\permit.sam O1/95 rev.l.l
___-_ �K 84
---- -- � 60' R/W
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N81'40'14��W
R08ERT W. McCULLOUGH
D.B. 190, P. 459
(ORANGE C0.)
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MARK JOSEPH M
D.B. 237,