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A32 166,� �0.�.�a � ��. ` �.s�C" �=; :-. �� • , � O � d z ��- � �i� _�: ; . � Improvements Permit.(Fstablished/Recorded Lot) Permit (Unrecorded Lot) �� ,3 : % � _ Reinspection of Existing System (Loan Closing) ace existing Septic System Improvements Permit (Mobile Home Replace) _ Permit for New Well - Improvements Permit (Addition) _ Replace Existing Well . � � ` < . y; 9 `ux�� x; �. ,.�Water Sample �o,�be Coll�ct`ec�.s �;;s �� y;� _ , w � > ..�. .::. � _�M... .:. .< . > ., ::.:..:.<_..:_. . . �... _ Bacteria Chemical _ Petroleum _ Pesticide Permit requested by: . . ner/prospective owner/agent:�y��as �►Trir,�r. . � . _ Z'orai�t ne Phone #:� �llU -� � `7 !� ��o iness Phone #: _ Name and address f:current o �O.V�� TO�' . Lot size: Tax Map# Parcel#: .'� � Township: � �`� _ Lead 7. Dimensions or Proposed Structure: Width: � �o�nble- W�d� 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? � eri c ions to propert�,Y: State Road #& Road .mes;�tc. Tt IC� lfurz��c m� 1/ �al fa � S r �� v � t�s .�'c�l A ' �ti�i/�s �urYL l�; h f- on ,Tccck C'(�Qiirs /'a� '��rl� n ��`!� f- ,bC/��c�l �1i/r'_ ('��tce l L'hurr-h • ,N of occupants or people to be.served: � 9. Water s ply type: private public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No [�. If so, identify location: 1. Type of structurelfacility: Proposed: �Existing: Q Type of dwelling: � House: ❑ Mobile Home: L�J Business: ❑ Type of business: Number of Employees: Number of bedrooms: 3 Garbage Disposal? Yes a �do � Basement2 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 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. � � ` Signcc� Owner or Authorized Agent ; 0 Permit Issued ❑ Permit Denied ❑ Plat Observed ❑ Signature �v ��s s i� �—'- C ��►�x c�d,�-�'t 5 u 1� � ♦ . . . • . �. Date ' ' RECOMMENDATIONS/COMMENTS: SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope patterns, etC.� C:WMfPRO�DOCSIAPP5EC.5MFWANCE.PC .� � W � a � t �. B 12 9�9 PERSON COUNTY HEALTH DEPARTMEN'I' WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT 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 # /� � Z Parcel # I�� Zoning Township ,� vs y �/ �G;zz Owner/Contractor �?'No•��j � i,��nlA TL�zi��.�/ Date i� ,z �/4� Location/Address t/wY i5'7 .–o�A�za .r/��r�r �+-,��c� i/ �^' l�-+��$s .z�� /l� �,�! 7�k c.fs�v�S ,zn � .�, /e �� .P�_ S.R.# �l�'��.— Subdivision Name Lot# SEWAGE SYSTEM SPECIFICATION3 Repair Lot Area t� A� Size of Tank >[�oo l,� z SFD Mobile Home Size of Pump Tank � i�,�,C �� Business # of Bedrooms�_ Nitrification Line �o� � X 3` Max Depth Trenches �?o "-zy ►` Permits may be voided if site i��ed or intended use cha ed. Well and Septic Layout by Comments: o,. - zv " iy� x 7nt �� .�c Cp � Z !� .� .-,�/ �/i i,� �� c A 7 0 ' Date • 6 Installed by�'�� a i Approved by f - Permit Paid�57' WELL SYSTEM SPECIFICATIONS �idual t� Semi-Public Required Slab 1/ ic �Replacement Air Vent ✓ Approved Required Well Lo� ✓ l Head Approved Well Tag �� Pc_ G, �tino Anr�rnve�i �/ C �. Comments: � 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 eavironmental 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 � — _ � � 0 n 29. 93 � S C Q C � =v � _� � � � 4 �_ k N � V J1 �V � � .Q �" I � � ' �' ,7�f � . � � � : S-II-50-52-W 204. 91 � 358. 33� N-II-50-52-E c t 123.49 � PERSON COUNTY ENVIRONHENTAL HEALTH ��' i .+ - _ � . � _ , . � Date: / / ' 9 7 � Owner. �-,y,� Location/Directions: i� �.�tie �,� Subdivision �Name: Drilling Contractor: Distance from Nearest Yroperry Line /o'-�- Distance from Source of Pollution ��i '' ' Total.Depth:� �v Ft. Yield:_ /s� GPM Static Water Level a�' Ft. Water Bearing Zones: Depth _�'� Ft. ia3 � Fc. �� Fc. �c. Casing: Depth: From,�_to�a _Ft. Diameter:_ G`/4 Inches TYPE: Steel - Galvanized Steel � - If Steel, does owner approve: Yes No � Weight: � Thickness: /_ HeightAbove Ground: / 4 Inches Drive Shoe: Yes v No Were Problems Encountered in Setting the Casing? Yes No � If "yes" gir e r�ason: Grout: Type: Neat Sand/Cement ..-• Concrete A.nnular Space Width Inches Water in Annular Space: Yes No _ .. Method: Pumped - Pressure � � � Poured � � - . � - . . Depth: From � to a Ft. Materials Used: No. Bags Portland Cement VVeight of .1 bag�_lbs. If mixtuie (sand, gravel, cuttings) - Ratio: to ID Plates: Yes �' No � � 4 x 4 slab Yes_� No _ DRILLING i _cXt " WELL LOG SR# // 7 ,.. .tt Fmm To _Formation Descrinti 7 I 3� �� / ia '/� l4�lJ I HEREBY CERTIFY THAT THE ABOVE INFORM�ITION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY THE PERSO�J CO`Ji1TY HEALTH DEPARTMENT. �' �� - _ Signature of Con�ractor Date � PERSON COUNTY HEALTH DEPARTMENT SUBSURFACE WASTEWATER SYSTEM MONITORING REPORT 6 �� 1 Z l� �6 32 1 l�f� Date f spection System nstal ation Date Type Tax Map Parcel # Z2� �ac� CGra�.;s �% T.�,b�-laK� ,�. z�s�� Property Address Instructions: Check yes or no for appropriate items and explain in space provided for renarks and comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate by "N" and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance and monitoring items specified in the permit are to be carried out. INSPECTION RESULTS COLLECTION SYSTEM: Evidence ofleaks ? Tank risers accessible, free of infiltration and surface water diverted ? Septic tank needs pumping ? Inches of solids: Septic tank filter cleaned ? YES / NO ❑�❑ ❑ / ❑ N ❑ / ❑ EFFLUENT DOSING SYSTEM: Required pumps present & functional ? High water alarm operating properly ? Floats, valves, etc. in good condition ? Control panel & components in good condition ? Effluent free of excess solids ? rr Inches of solids(pump/dose tank):�_ Elapsed time readings ? /�" Counter readings ? Drawdown rate: N O� I�+ i ■ ■ ■ ►• ■ DISPOSAL FIELD: Evidence of effluent surfacing ? ❑ Evidence of effluent ponding in trenches ?❑ Surface water effectively diverted ? ❑ Diversions/swales properly maintained ? ❑ Vegetative cover maintained ? Protected from traffic/unauthorized uses ? Distribution devices in good condition ?� Field free of settled or low azeas ? � / / / / / / / / � G ■ ■ ■ ■ PRESSURE DISTRIBUTION SYSTEM: Turnups/cleanouts/valves/taps intact & accessible ? � � ❑ Pressure head properly adjusted ? / ❑ /� COMPLIANCE: Compliant Non-compliant Needs Maintenance ADDITIONAL COMMENTS: EHS rt� F: ■ r: . REMARKS .._. �,-h ��-a� 1� uo�- a-cc�ss �� l� Q�C -- �Crn-� �� 3-+`se.- 1► c� ��s .�14s1� n-� � �� —�v�a�on�- a��Y�,C?� t�� G�t.�of�'�� hc� j��,k �� C��-��ol �� 1 _C�✓�d.�o� �( t�ok 4cc.��srble �u�e. �o v� �►eY P�a n��W i n�4 liv'�'r' �`"}.• � �1� �,u,�,� �- a la,-.� f��Y �t�� -� � 5�� ,�, Ini�l.Q,,� �i�,rv�P IS 1'N�n�� Sory�2 HJa�' iS U Yu�� K� %C� i�� .��,� �'�c !� -��ir`( �'�1� (�l/r*''�'e� Q��✓tr� • �il��r �6lr�P `(��°1'� i S C�CK�Q v�' �►"�,�.0 � w�� S hPr� C,�s� � 0�'��►�r�'efaQ �,�r -��w1� s� ; t ,