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A32 172� O � � w U � a �p� .UC� 1 i � ��A��1 `::� . FF.'Ot�l PEF.'S�hJ•CuUfdTY HEHLTH DEF'A TO -. _. ,,.�-, -- - ----. . �-a0-�7 191�+'�32555�18� P.01 Xrnprovem�nts P�rmit.(F..stablished/Recc�rded Lot) �. Reinspection of Exssti Improvements 1?ermit�(Unrecbrded Lot),• Repairl�teplace existi� I�nprovements Yermit (Mobile Home Replace} ��ermit for New WeilM System (Loan Closing} Sep[ic System �� Tmprov�ments k'Ermit (Addition) Replaee �xisting `Vell � _ � Permit requested by: . ne. prospective ownet r�ss: �(1,U1QQ ('�� oit�e P��otte #�I�G' 4'•I�� usiness Phane #: �I ��1-�-!n l� l t�a�me and addreSs of,current owner: 7. Dimensions,or Proposed Stn�cture: Width:�_�EO� Depth:_„__ 45� - $. What type (if any, additions, �xpansions, or � replacement is anticipated to the st�ucture c�r facility Eha� this sewage disposal system is int�nded to serve? Propert�� Descripti�n:- Lot size: 1���3 LtIZ '�ax I�'�ap�#: �} 37! (�� Parcel#: �_�A Tow�lship; r� ti(,� Ik - ��, � 37irections to praperty: State Road �& Rc�ad ✓ames,,�tc. + �A� Nn,M �nJ I�n,-n .-M �lD Y-GA��Q_ NU ��St�: � Nutnber of occupants or pcople to be served: 9. Water,supply t}�pe: . private� public ❑ community C� spring ❑ Are any welis on adjoinin;� property?Y"es`� No j�' If sa, identify locati4n: _L�:'I`�ype af structurcifacilicy: �'ropased: �xisting: Q Ty�e of dweilj.ng: �iause:C��Mobile Home: C� Business: C7 Type of business: ,Number of Employees: Number of bedrooms: 3 Crarbage Disposai? Xes ❑ Np � Basement? Yes C� NoT� If so, # of basement fixtures: CLTA,.I�LX ST�.� ALL CU�NERS OF'��E ��20PERTX ANYJ TI� COX2.NEkZS C» �►r%L � pROPOS�D STRUCX'UR�S• 1, hereby make application to the x'ersOn Coul�iy ��aith De�artntlent for a site evaluation for the on-site , se�vage disposal system,for the above described property. T agree that the contents af this applicacion ac� tnie and represent tite maximum facilities to be placed on the property. 1 understand if the site is altered ar the intencied use changes, the perniit shall become invalid. T und�rstand that befare an Improvements Pe�cr►it can be : issued, r must pzesent a survey plat of the �roperty to the Health Dept. I ut�derstand that in the cvent � have not �; dcliv�red a survey plat of the property to the Health T�ept. within b0 D A, X S a fter t he date of the evalua�ion of , the site by the Health Dept., this application shail becom� void and ail fees paid forfeited. � ..�.i1gt1C(� 'l1P�r "•,l,li{�ri•r�.� /1 �rnl .'�' '�:d�. ��.� �. � •�Ti�'� ai'�t o � t � q�o� � Dtw � . •�`, � ��S«� . . .� . � .. .�-� -� e�'i� T'[� � °' ,��.,,x.,f,.,.a.�c r _ . ..,,,,,,�..,.-....R........ .-- . - - , s""- . . �: ' �}. ,�•E� r.� . . �:�'t ;`; `� �• N � � N � �y� sw�►0�7�+�. � ..... `�.�irw�+ w � � ' �+Y'�".. - eww � n�m� , P � f t,0 � \� � F�-+ � ���' '� t�b ��° �� �`c.. �� � � r r � , ��� � � �7`'� r � � z H� L) p Z C N O Z H� LI � D G'7 m � � � � B 1516 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IlVII'ROVEMENT 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 # � 3 � Parcel # � � � Zoning —t' 1� n �� a c� S'�S ti% Township �=.�►r � �� Owner/Contractor A,.�� � � � Date _ Location/Address ,[/�,�/Y /,�-7 ic�.a�eo /./v��[� �nit� 5 i,��uc-^sS .2D � /l ' cr , � c - v .�'� $.R.# /S7 Su division Name ,�?o, �,,,, �r M c.4 D o h1 Lot# � SEWAGE �YSTEM SPECIFICATIONS Repair � Lot Area �s, 73 � c Size of Tank �ovo l�,� � SFD �� Mobile Home Size of Pump Tank ,�//.a Business # of Bedrooms� Nitrification Line �/Bo ' x3 ' Max Depth Trenches i� �� -zv " Permits may be voided if site is altered or intended use Well and Septic Layout by_ Comments: /L� "- zo'' .te r"I -- I b-�$ Installed b� ell Permit Paed ❑ WELL Individual �/ Semi-Public Public Replacement`_ Site Approved Well Head Approved Grouting Appraved I Comments: Date �i ��q� Installed by, r= n1� �� Q� f�T/-/ �DL � o w C'�•vTOv/Z ..� - -� P� o ' X 3 � L / �1� �— O,�,v-{.o Approved by a, o o q -a.�-�l � SPECIFICATiONS Required Slab Air Vent C_._. Required Well Log � � I Well Tag ��,{�� n'L �iSyy . —' v . v This report is based in part on informat�on provided the homeowner or lus/her representative in the application submitted for this permit. The environmental health specialist is not responsible for false or misleading �nforaiation �' contained in the applicahon. The environmental health speci�list is also not responsible for concealed conditions on the property or for statements in this � report that may have resulted from faIse or misleading statements provided to him in the application. Neither Person County aor 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:\amiprolpermit.sam O1/95 rev.l.l � -. � �� ' . .� ... ... .. . . .. . . .. . .. . . .. . ..,_..... . '�tt c' t�. � ti.rs: . ;S3 C:' Y�55� �i ��1�T� -k,s,�r/ �� : � . � .i' � �4. ;J s . � 1 .�i�. P� . G � ti ,� . 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'��: 1. . r, �it .•9 •1; i`,I �, : i�• � � ` 'l:HI;T�OSvMk:N'I'AL ;HJ•:ALTH; : ; `� • �.� '`'`; ,:; �• ;` � '! " : � •4 � � ' :w�EL,iI;�:�oc; •;; 'i , .�t �; ,� ; ; . f ' . i j. .,;..�: •, , • � , •; : � • . :. ;'. {.� �n '�' ':b 'e , .7. .I • �{ �i�i �J':: �. ;� } '+ r'��'� �C �'Pi •:i . . � , �4 ' �' � 4 '; '`��. tr.:y� : � . i . �; .;. . ,:: q� �y :. . 1. '• � SR�� _ _1 ' f— :�-�- '„ ,�� " � �._. _... .—.. —. , — — _. : ,I � r :i J�. ,✓ t � :; >;;.�..,�._:_��.; : . . � ;; . . . : � �; '; � � � � � �' �t.Ut #�� '.� �� � : . ' '''� . • ;.�: ;! ; --` , .�.�.. ; . .�. _. . ';�, �� • . -; _ . --�--�- . �� ST� (31�1� ; ; �_._.._..,.__� ._ _ , ` ����.. � ti� �, Distanci: frc.i�tZ �Sc�urcc of � . Pollutian— f1�,S" . . ��:�i �� �� `` ' �` . � ' � Toral Dcpch:�� Ft. Yield: � r�'� `;:::C�;,M Stac'c, �� .j c�,� •:' i ti ate� �.,cvel -�t. Water �caring zoncs: Dcpth _ j8o Ft;�_�F� � Ft,____�,Fi. �. Casing: Depth: From �1_____to.,. �� �Ft: T�iameter:— l�, __��hcs !• TYPE: Stcel G.11vai�ixcti. S.iezl . . If Stc:cl. docs owner approve: '`�''es��_��%" ' NQ� : �,� Thicknfss: -�'�_ � V►leighl: � Hei� hl Abovc Gr t�nd: f� -�r��hes Drivc Shoc: Ycs�,�/ No � � ; � ' . ; . Werc �rnblems Encotuitez'cd iri"S�:t�ing t.�c Casin�? Ycti �' � t iC 'yt;s" gi� c rr,�so;.: � � ' �,:4 � ;� � N�'� Grout: Typc: Ncat Sani� -Cemcn[ <: �_ � �Concrct ATuiulaj Space Width___`_�'� � • `�� ��� . . � �;;� } ��—� � '; , ' Waler in �uiular Space: ' Y Method: Pumped � . � Dcpch: Frc�rn_ v ic �Ylatcrials Uscd; No. �a�s F �f mi�ctwce (s�nd, gravcl, cuc ID Plates; Xcs !� No� i,� �.��li ,. ;. . ;, �� ._i. ^: .; ;..; !/ . '� y _.Pourzd� ; � �i. .�. ,..?. � .. i.Ccny'�nt;�( � Wcight of 1 ba '�Rapci:,,;,.;���� tv' ��i� � ,'�•�.�� ' �I ;. �� . • ..�-.....�-..� ;: bs. ' � � - 4 x 4 siab Yes �No d`�a�' � "°" `` � �'r `� ' � ` '` � '� � '•'r. ' ' .� :� . ---...:T-�.; • . �, ;: , • �; ,� � � , . . . 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I��REBYCERTTFY FHATTi�T�AI301%, �NFQ�tM�'I'!C)I�nZS�COTtR�;C1'AN17T�-(AT ���5 ��LL WAS CONSTRUCFED II� /1CC.nRD�NCE WI fH.1ZEC�1J1.,.AT1C)IV� Cf:T FORTH �3Y�THF PEkS(7��I G(iUi� 1'Y F�LALTH��EPAR'f'I1�1�'�j• • . .y.. . . a . ����..�� �� � �.. �..� �.. ���� � � ��.'��. � � .� .t I , . � � �.����c�._ ._ ..��1-9 � � Si�ti � �ic,�f G� . . �` : - , j, �� , J1tflGlt�C . . j.�a�.; ;�� • :. . . . . . . ��:� ��. . . . . , •:, .; . . . . ,. ...__'�.�..;�_....._ _.....------..:----•-.�_,,.." ;';": .. �. 1