A32 171�
H
O
�
:�
�
W
U
�
a
P �, , 0 5 , o d ,_ _.._ . . � --... �--� ._ i � - �.,�
�v
��� APPLI ATI N F R ERVI �
, . � �„ . ,
� .. ���^� � p��C' t.�i:. ,r x - �rw, l: �. �.ex�'.,� � s_�`r.;. ."` � � 4�t l(yf��
a ..' f^'� ''� l.[��' �( '
. :. + 1� �$ <�.i� 'r'.. .. l�� �R
..,a S . K+—c•...Y'`t } � ' s"'
, "�,� x ervices�Rezuested �k
p A . d 'k1'iy S e� o.wA�%+�.�v� . ir�n.a+... .... :
1
,. . ...Z.� . �.�kY Y . .....x�d.�crr+v?�•r . � ..
tr� Yr�e�+�.�'�'..;���wii`� � . ../..f..1�?F'.. .�.C3. .iG .J[ ... . ... . .
Reins ction of Existing System (Loan C l os i ng) �
v I m p r o v e m e n t s P e r m i t.( F s t a b l i s h e d l R ecorded Lot) _.. Pe
Imaxovements Permit (Unrecorded Lot)-- _. Repair/Replace existing Septic System
_ Irnprovements Permi; (Mobile Home Replace) ' _ Pe��t for New Well
` Improvements Permit (Additio�) _ Replace Existing Well
.}!Permit requested by: .
owner/g�o-�gp,.f• :,.... .... p M� k�.l Park•r
"b'"
Address: _ 3s.3s l�a,a•.µ'n«�2�,t,_.
ome Phone #: �t19-'1��.•�3��
usiness Phone #:919•�3�. -g�'+�
2. Name and address of:current owner:
w
�
z
7. Dimensions,or Proposed Structure:
Width:�� � ���-"
Depth:_ 4-`'► '
8�I
$. What type (if any, additions, expanstons, or I
replacemenc is anticipated to the structure or facility
tha� this sewage disposal system is intended to serve?
I ' A�
S�� ,br o,,_I9• Water.supply t}'pe: ❑
Description: Lot size:�s
Tax Mag#:� 32
Parcel#: Z3
Township• ► ��T 'Fo�1i.� -
. Directions to property: State Road #& Road
ames,�tc.
,.,� IS�I. �d H�.r�(I.� !�'1�,'/Il
r i.
privatei.'�publ�c ❑ community ❑ spnng �
Are any wells on adjoining property?Yes`�J'No �
If so, identify location:�-io�s�. lo c��Ee o
rieri�tuf�s'� a�ofostiM.���•, 12r„'
' �Jw. s,'f4
of structurelfacility: Proposed: �xisting: C�i
Type of dwelling:
House:C+�Mobile Home: Q Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: 3_
Garbage Disposal? Yes ❑ No �
Basemcnt? Yes ❑ No�If so, # of basement fixtures:
' t
6. Number of occupants or people [o be served: ,3:—_
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pei'SOII COUIlty �ealth Depai'tment for a site evaluaii°ation ahe t�rueite
sewage disposat system for the above described property. I agree that the contents of this app
and represent the maximum facilicies 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 Impro� the event have not,
issued, I must present a survey plat of the property to the Health Dept. I understand thac in
delivered a survey plat of the prope�ty 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 forfetce
� .. .. �1 --
i
�
S�`���er or Authorized Agenl
�
a
w
�
a
B 1475 -
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT PERNIIT
Not for waste water system construFiion. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # A � z Parcel # ��– / -7 � � � ���/ �� 7
Zoning Township ,=L„ ; z, �� rL
Owner/Contractor kC,�i ��En �,,,� Date z/�T/,�7
Location/Address��,�y , S, rv �.�u 2 D c� i•� � c� s i/( �= �✓ �t s�
l2 i� ��/,� O.cl j� f� �f T ,�;vs i.4� �����s G'. Mc�Jk,ey�R.#� f.S-7
Subdivision Name �U � L i n! C- .� �,a ,o � r..t s Lot# S
SEWAGE SYSTEM SPECIFICATIO►NS
Repair Lot Area �; �B a c Size of Tank �c�oc� �.4 �
SFD ✓ Mobile Home Size of Pump Tank
Business # of Bedrooms � Nitrification Line �o n' x�'
Max Depth Trenches � "
Permits may be voided if site is altered or intended use cha
Well and Septic Layout by j�� � /��A .+ •
Comments: i� r' ,.,�,4 u T�� � c �.� �� �,,
ate a– Installed by
ell Permit Paid
te Approved
ell Head Approve
•outing Approved
Comments:
WELL SYSTEM SPECIFICATIONS
Semi-Public
Replacement
c_.,.�r s c .✓
Required Slab 9V
Air Vent �
Required Well Log
Well Tag �%`—
This report is based in pa�t on information provided the homeowrier or his/her
representative in the application submitted for this permit. ']Che 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 tlus
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 01/95 rev.l.l
11I12�1997 09:09 5971i99
r �,� •�� �
� �
PLANhIING AND ZONItJ"`a
� �� � 1
,,��n � ,�
�� � ��t�St�-
�
+� 1
':?� t,� � � . � �� ��� , �'-1�3 ��-�., da
� _ �r� � �
_ � c.`�', `�''�� a�a� -�
� �
�� '��s�
j - 9t� • 1� � 91-N
h
�
�
1'.
~ "� f � .o�
�
�
�
;��t�,,,..,
,8'� ��a
��
�� �-��i
�`"�'�... <<.�~!c ��•-
0
.
PAGE 0�
.
'��
�'_" -- �r �✓ �29/ , . `S- �t
�- . , , �� �4. 3
.--� . oo ' S�_
� f �s„
�
N
ti
N
v
r
0
_ �
_ "v
�o
, ��
� -._4^_ii
J�. ;,�
46a'x3` , cv
, . ,- ; �
N
, �/ /`�'
"�c,( '
'Se
y� �
���, ,
a�3 �2
4
i.J3 aC.
N-74-56-48-E
442.47
3
N-74-56-48 - E
N-76-37-46-F
0
�
QQ Ke�Q ,d�� � �n
P�
OO Ke� ,,Je1) � ' �T
Q , , ��-.� S o�,
��s� � ��"
�,, _ %� , �n ����
-�
440. Zp
i
�o' R�w ...,
2.42 aC.
,
c
��YSa1 %,�' .�� . ��'
,�aS S. ,,�,or s'f� 1
(� �'�' . - -
t�p Y..� a y/d � 1SG ,�rl �7� ��
,
I- --- _--- - , na au;irni HbLL
�:• �: �;.;_
PERS:1'C1 C(.�t'�+iT]�'.�B'Fi�IB�bNMENTAL C�ALTH
?- NBLZ LaG
I��.V`,,,r, " -
(�wner. . �
"ts . ir�ctio �
� ��� • � - �n
Suhdiv�sian �Ivame _
Drilling �on�cto .
}— [¢J 0 `L
h—a.�(,� �{�C1 i���-��i�
wCi.�. 4w,�`�„ i n�.+ �l� -
. Distance fiom N� t pnogerty Line�_„_.�., 17�istance fnom So- �e of
Pollution � . � :
Tc►tal �epth: �� FL 1{i+�ld:.�_ GFhi St�t�c �ater Le e1�Q.. _Ft.
Water �earing �o ; Depth �� —FC. Ft� � - F� �.
+Casing: I7epth: � in. � to �� Ft. I?iam�ter. Inches
TYPE: SGeel � � _ � �Galvani2ed Stee] �
• � If Ste�.1, �s own,�r appnov�: 'Y+�s i`�c� -� �
''y�eigh� � Thi� esS:�C�. Height' Above �round: Yn :�cs
. ilriv.e S� e: Y'es_� 3�'0 . � �,,,,�
. Were Pro lexns.Encauntered in Se�ting the Casing? Yes Na,� :
. If "yes'� g ve reasa�: . -�----�-
Graut� .�'Type: " N� at _ � � Saa�dlCem�nt� � Concre e , ._
Annul�r; par.e'Widtk� � �' __ �, ` ��� ches ' .
Wates ue i�l�x Sgace: � Y�ss_���,.,.. N'o -
� - Methad: �uinped�:_._ P�r�ssure Poureti
I�epth: m� to �t� . ��
�� Macezi Used: ltil'o. Bags Portlan.d +�ement„r�V�eig�it f l�bag, �� � r lt�s.
If mix '(saraci, gra. -�uttings) - Ra�ca:__________ ta
. �xD PIate : �Yes - �Ta � � �� �
��� x d� sla Yes Na_______
� . � . . . � DR7L�NG I�Q�
I HEREBY �GER
'1'HiS i�,►ELL V�t�
F4RTH BY'�TH'
�
�
EFY' THAT THE .�U%►E �F0�23vir�TIt��1 IS CC
i CC)1'+TSTRUCi'E�.7 I� A��(�R�A1�CE ViiiTH ]
p�,RSO�l' C�}�.JN"I"Y HEA►LTI-� I7EFAR`fMEi�1T-
--_ _ s^ i
f Contractar
*
EC'�' A�'� 7'I'HAT
UL.ATI�: NS ;SET
I
�
. ,�"'�j "-c
a
(yate �