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1919'i �255501��J P. 471
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If so, identify location:
of structurc/facility: Propased: �xisting: [..I
�ng:
IV�obile Home: Ll Business: ❑
�'ype of business:
Number of Employees:,r...�
Number of bedrooms: �—
Garbage Disposal? Xes � N4 Q
Bas�menc? Yes Q No� If so, # of basement fixtures
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�LEA.itLX ST�.� ALT. CO�tNERS OF T�iE 1'�L4PERTX AN� TI-� COX2NEKS Q�
pROPOS�D SIRUCX'URFS• �
1, hereby make application tv the �.'erson Couxtty �ea?�th De�artr�ent; f�f a site evaluacion for the on-si�
servage disposal system for the above deseribed pco�eccy. T agree that the contents af this applieation ar� t.cve
and represent the maximun� facilities to be placed o�� the property. � understa re ntltrisrovemerits Perm t can
intended�use changes, the pernlit shall becon�e invalid. T und�rstand that befa �
issued, I must pKesec►t a survey plat of tt�e property to tlte Health Dept. I uttderstand taa�e �fhhG evaluat'oit f
dcliv�red a survey plat of the propeny to the Health T7ept. within GO DA.�, S after the
the site by the Heallh Dept., this application shall becom� void and all fees paid forfeited.
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT
B 2226
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 # � �.?i Parcel #_
Zoning ►-�a Township
Owner/Contractor Y G,) ` `c
Location/Address _ is� y, ��, ;/�r S�� �.
Date �� ��L��
S.R.# �/J o
Subdivision Name��; /yJQ' o Lot# �
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area f.93 �' Size of Tank /G� c�1�s
SFD � - Mobile Home Size of Pump Tank a/+9-
Business # of Bedrooms 1,� Nitrification Line_ 3;GSl� �� /ffia�.��,yi�
Max Depth Trenches /2'�,a�ec. � � �
Permits may be voided if site is a
Well and Septic Layout by_��
Comments: /��d Sr,��1/�,., G� C
Date I I 1 Z 31 �}� Installed
ntended use changed.
Approved by
ell Permit Paid I!Q WELL SYSTEM SPECIFICATIONS
dividual_�_Semi-Public
iblic Re acement
re Approved
ell Head Approved
�outing Approved
Comments:
Required Slab _
Air Vent
Required Well Log
Well Tag
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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. Neitner 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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Location/Directions:
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PERSON COUNTY ENVIRONMEHTAL HEALTH
WELL LOG
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Subdivision Name: ._`�-�p �� /`-�����,�5 Lot # --
Drilling Contractor: -
. WELL CONSTRUCTION
Distance from Nearest Property Line �O Dutance from Source of
Pollution lbC� `
Total Depth:_�__ Ft. Yield:_�__ GPi'v1 Static Water Level�_�=t.
Water $earing Zones: DepthZ,����►��__Ft F�.__ � Ft.
Casing: Depth: From p to�_Ft. Diarneter:�ls� Inches
TYPE: Steel - CalvaniZed Steel .�-
If Steel, does ownerapp:ove: Yes No
Weigh[: � Thic�:ness: •(88 Height Above Ground:�_ Inches
Drive Shoe: Yes �"� No
Were Problems Encountered in Setting the Casing? Yes No�
If "yes" give r�ason:
Grout: Type: Neat Sand/Cement � Concrete
Annular. Space Width Inches
Water in A.nnular Space: Yes No
_ .. Method: Pumped . .._ Pressure � Pourul � .._ . . . •, � : .
Depth: From_ � �0 7 O Ft. . .
Materials Used: No. Bags Portland Cemenc Weight of .l bag__lbs.
� If mixture (sand, gravel; cuttings) - Ratio: to
�ID Plates: Yes � No � " �� �
� 4 x 4 slab Yes�—No
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AI�ID THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH �y�THE PERSO�t C�Li�'I'Y HEALTH DEPARTMENT.
ignature of Con�ractor Datc
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AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: j- I p-�1 g IIviPROVEMENT PERMIT #: BB�b
TAX MAP #: %�"�� � PARCEL #: /'� --rr.� Y �/
OWNER/OWNER'S REPRESENTATIVE: Ka}-h ;/._ � �S
LOCATION/ADDRESS:
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SUBDIVISION NAME: LOT #:
SECTION OR BLOCK:
. AUTHORIZATION FOR CONSTRUCTION ISSUED BY:
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AUTHORIZATION CONDITIONS
1. The Wastewater system construction and instal[ation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Pernut #_'2��� . The
construction and installation must also meet alI applicable rules and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Heatth Department.
3. Any alterations in site or soil conditions (including stnicture locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and appIication, may void this authorization and associated pemuts.
4. Conditions:
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Person Requesting: