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A32 168� _. �: Fy O a � � w U � Amount paid l� � �v� Receipt .� � 1�l�.( _.-' " �� � ��� �.����� -1 Date Improvements Permi[. (Established/Recorded L,ot) I_. Reinspection of Existing System (Loan Closing) Imnrovements Permit (Unrecorded Lot) Improvements Permi[ (Mobile Home Replace) Improvements•Permi[ (Addition) Repair/Replace existing Septic System _ Permi[ for New Well __ Replace Existing Well Permi[ requested by: . ner/prospective ownerlagen fr7 ome Phone #: 3� rD -���-t —�3'� �i 2 -j� ��� �e usiness Phone tt: �sv�.v��_ �� � I�Iame and address of,current owner: Property Description: Lot size: 2�� �+�c Tax Map#: � 3 �-�' �. Parceltt: I G i�a��`� Township: �a��,.x�_ v�«.�.5 _ !�e`''�` Directions to property: State Road #& Road ames,�tc. �.�.� �s � �.�,,� �, � m � ��s C � ��� �.�-r � -c o _ Number of occupants or people to be served: 7. Dimensions or Proposed Structure: Width: _�2. �� Depth: 2�l �- What type (if any, additions, expansions, or placement is anticipated to the structure or facility at this sewage disposal system is intended to serve? 9. Water s pply type: w�L�. TG �� ���-�w�=n v�z _ w�� � �-��_ private public ❑ community ❑ spnng� Are any wells on adjoining property?Yes ❑ No � If so, identify location: 10. Type of structurelfacility: Proposed: C�Existing: Q Type of dwelli g: ' House: �obiie Home:O Business: ❑ Type of business:_ �i°r Number of Employees: �� Number of bedrooms: 3 � Garbage Disposal? Yes ❑ No � Basement? Yes ❑ No��o, # of basement fixtur�s: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the PeI'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 con�ents 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 pecmit sha11 become invalid. I understand tha[ befoce an Impcovements Permit can be issued, I must present a survey plat of the property to the Health Dept. I undecstand that in the even[ I have not delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date oE the evaluation of the site by the Health Dept., this application shall become void and all fees paid forfeited. Jan 06 99 03:14p � / � • . �� �i . �� �' N-74-56-4g-E 442.47 3 ^ 2.63 oc. p.2 V � V � � • � � j � . N � ..� � � � t v, , � t �' �o I "� f 1 :. N-74-56-48 - E � � . 4a�.55 g . � � � � . - . - s�� - � � �� � ' ` J • � � — �+r ,' F _ �� O � �. ��' �C ! � � W ;- � l�y � S �O � .. J� � , �� -�' . N - 75 - 37 � �v .. � � � � „ . � 440.20 • � � � Lt 3 � � � � � � - �- � _. ir � � t L S � , �. �� ��. � . p � � _ . � . i �D T3. . � . � N. �ith �o�h� � ' i �. J � a w � a -- B 2670 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT 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 6een issued. Tax Map # t-t 3� Parcel # Zoning Township Owner/Contractor Location/Address Subdivision Name Date �-1— �i '�' � rn� S.R. � � I S� Lot# � SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area �.% B�G Size of Tank �(�,� Q— Z r�; 5�er's c�.: ( SFD �� Mobile Home Size of Pump Tank Business # of Bedrooms � Nitrification Line �}p�`X�' Max Depth Trenches a� � � . ��� �� Permits may be voided if Well and Septic�L�yout by_ Comments: � �� � or intended use ch Date v Installed by Approved by Well Permit Paid ❑ WELL SYSTEM SPECIFICATIONS ividual ✓ Semi-Public �lic Replacement. Site Approved Well Head Approved Grouting Approved_ Comments: (�[� Date Installed by Required Slab _ Air Vent Required Well Log Well Tag 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 l�-er Jan 06 99 03:14p � � / N-74-56-48-E P-2 V � 8 � o � 442. 4 7 , • o A � �� ' � • N � .r... m � o . 3 � ! � . � tr� � � t� ��� '� �' �.f 9 oc . - � �� N � � � cv N-74-56-48 � . � � 440. ��� g o �<< � + � �\ , � � ; , — � �� � ;' , � � Z �D � � � . - 2. 8 -,- + , z `�o � � � tD � N � '� _, S , � � Lai (� �, � � � � � � � � _ � � , ' � ?5 -37 ..�� � . • - -- w � . � aao.2o - � . � � Lt3 S � � � � � _ � � _.. �- �. . . � ' '�s o , 2. 42 �c. �; o . �, . � i � 3�0 � � � � ��3� � e N . Ke�rh �od�her � � ' � �.