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A32 176d � 6 �. .. . � °� � 2 ` z___. �' �- t �' e�- 6 � e��-�� �:�- ,�e. � � � �� - � nnT.i(`ATT(lN F(1R � � H O � � W U � a , � � ,� /. . 3 - )'7- . .3 -- ,>r.,.�. ..�..._ _... _ Improvements Permit. (EstablishedlRecarded Lot) ,_ Reinspection of Existing System (Loan Closing) Impxovements Permit (Unrecorded Lot) ,_ R pair/Replace existing Septic System lmprovements Permit (Mobile Home Replace) _ Permit for New Well Improvements Permit (Addition) B acteria .' Permit requested by: . wner/prospective owner Chemical ome Phone #:.�?�( ��- ��� usiness Phone #:�`��i �'1-1��U � _ Replace Existing Well _ Petroleum I _ Pesticide I _ Lead 7. Dimensions or Proposed Structure: c� idth: �(7 _ r ., .,,� 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? Name and address of current owner: 9. Wat r supply type: . (� � a � �S �3 �t A� private . public ❑ community ❑ spring ❑ � Are any wells on adjoining property?Yes ❑ No �. iL, .,��I I � nn a 1 C /�� _ If so, identify location: . Property Description: Lot size: I���i �� Tax Map#: Parcel#: _ Township:, Directions to property: State Road #& Road ames,�tc. � , _, , i Number of occupants or people to be served: l. ype of structure/facility: Proposed:�Existing: Q I I'ype of dwell}ng: House: ��Mobile Home: C� Business: ❑ Type of business: Number of Employees: Number of bedrooms: 5'� Garbage Disposal? Yes ❑ No � Basement? 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 Person County Health Department 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. 0 Signcc� 4'Gy ner or �i thorized Agent Permit Issued ❑ Permit Denied ❑ Plat Observed ❑ � . � • �.__ . .. Signature • Date� � � ,.: ,� 'x PACI'ORSSIIEEVAIIJAT70N, : ;>: .. ...; ...A1lF�i;1 „,''_. «. ARE�2..... ..s , .`_. .`.; �RF.�3 <:> .. , . :r k .1,UtFAd > sa..>'%` ^.:>a...Lv .:... ... .:.<. ,. ... . .......... ........ . . - �. s�.or� «� CJ% s s S PS a— 3 C b P5 PS PS U U U 2 SOIL7'EJC±VRE(12-36IN.) 2�� S S S (SANDY. LOAMY. CLAYEY. NOTE 2:1 CLAY) P � PS PS PS �(�} U U U 3. SOILS7'RUCIVAE(12-361N.) S S S (CLAYEY SOfLS7 � k PS PS PS U U U. 3. SOILDEP7II(IN.) S S S S �� ) � PS PS PS � F i� U U U S. RESTRICi1VE HOARONS (IN.) S S S (AlPERV10USSTRATA,ROCK) pLJC�/� PS PS PS u u v u 6. SOILDRAINAGF/GROUNDWATER S O S S S (DCTFRNAL & Q�TERNAL) ("Y� / I C�C. S U U U �. son r�Ens�un s s s s (PERCOLAATION RA7�.7 � ,' j L% f} U U U 8. AVAII.ABLESPACE S S S S PS PS PS PS U �' ll U U 9. S[TECLASSIFICATION(SEEBELO� SOIL SFAIES 5-SUITADLE PS-PROVLSIONALLYSUi�AIILE U-UNSUiTABLE RECOMMENDATIONS/COMMENTS: SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope patterns� CtC.� C:V�MiPRO�DOCS�APPSEC.SAi FWANCEPC -, - � � � � � w U � a B 1623 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMI'ROVEMENT 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 # /a 3Z Parcel # / 7� Zoning Township ��_ -o Owner/Contractor _Ti�s�,U � AY�-on1 Date y z� LocationlAddress �s � � i / �.� �—v� ss �� l . z _s-,_���s � �'� � � � - -- . . �!_.. � t K .' Subdivision Name � " Lot# SEWAGE SYSTEM SPECIFICATION� Repair Lot Area /, g8 ,� � Size of Tank o�oo ��. � SFD Mobile Home Size of Pump Tank Business # of Bedrooms ✓ Nitrification Line .�d�� ` X 3' Max Depth Trenches .zz" - z y" Permits may be voided if site is tered or intended use chan Well and Septic Layout by G� Comments: ' • �� _ _� �/a lo � z r� — �c71 . Date �-2 ') Installed by � 2 L� � 5 Apgroved VVell Permit Paid � WELL SYSTEM SPECIFICATdUNS Individual �/ Semi-Public Public Replacement Site Approved r/ Well Head Approved � Grouting Approved lv �. Comments: Date Installed by. Required Sla �� I Air Vent � �o • Required Well Log Well Tag 11�1�Z?� Approved b This report is based in part on information provided the homeowner or his/6er representative in the application submitted for this permi� 'I'he 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 properiy 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:lamipro\permit.sam 01/95 rev.l.l - i � _,__ __ _ '`` '''/� � � � ��� ��� � -�------- j .; 5� �'� 94.0' � : _ , l � , LOT 1 1.88 ACRES � � : i� I4g ,,�,e: __--- ; �� 30.00'� � . i I � � i � � I N N O v O . � N P OPOS Q N � 4.., B ILDING o .. � � o ��- � _ .��, so.00' ,- �, � N ������ :: o r� � � ,t c� o . � � a ,�,�: _. � � o .�.: �.: �. d i � !� .Q �j�,� o��:�-;.: .�.•. � � � � p C � 30.00' � � , 1C , � I � �-- Q O h��� � �� 47. 7' n �D � 48.4' : 't � �� � � L 300.80� � I ` • �J� � �1. r _. � � � � � � � � � � 1 ` `, �, �. 5 a��5�� � O � O W ' t0 IO ^j O � f*1 I � . I 60.00' � 4 � � i�i:r,:,�,r� r.ui�N�i��� i•:NVI.ItUNP;::N't•��i. iii,ni.��'ii IJI•:1.1. I.(1(: . Date:__L �./_��7 Owner: —,�'�_ GLfr- , �,,,. Loca[ion/D�rcctiUns: __.� � y/,� 'l _ . . . ---------- S�2#� � ��:���visiUri N�1n��C_---_� _ . ---- '• . Drillin _..----. � ._ ._..._.______ Lot �� � Con tracto,r: __ ` .. . . .. �J� n.t_:.1,J� l� .�C?. r'..:.-1l_:- n-_-S .--- � 1�1::1.( . ("�'(�7N�'('l� 11C, Iil(�f�! --- Discancc from Nc�u-cst ]'roj�cr�y [_,i�u� _ �S ..--_ --- - Po]lution�_p � u,s ��-�.�_ llitit;�t�cu lrom Source of ' Total Dep.th: � •• .� . .[�t. 1 �c:lcl: %S .---._ _ .__ ��a'M .�tritic WatcrLevel rj Watcr B�earing Zones: lleptl� . l:t. � �Ft. �. Caszng: Deptli: FroTn ��._�-� :.. i�8' ____1�'t.�_ Ft._____-�t. TXPE: Steel . . �.� __1.�. Diarnctcr: �� Inches _ G:ilv:uilzcd Stccl � �� � Z.f Stccl, docs ownci� ,l��p�-ov�;: �'c:; ..___ Nc� � Weig}it:��'I'llickncss: -� . --' . ; llrive Shoc: Xcs___— `�—��'"-�-'!;[c�g1�t Abovc Grounci;_______...`Znches �. Nc� Werc Problems Ei�countcrccl i,i .�c:ttint; �le G,sin�;? Xes '� --' , .�f "ycs" �ive rcason: --_. No�_, . 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( �I .. .. .... . � ..� - • . . . . ... .. . .. . . . . . . ... �. _ .._.:� ,�..y....�.. ........ ...:..�....�.......�.�...»....... ...�,........... ..... . ..� ......��. ...,.�...:. . . . . , . .� r�� ... ..... . . �. .. :.. _�.� . . .�- rt,�r, � �� . .. .... ... . .. .. . . . . � . . ....�.. .+r � > AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (Void sixty (60) months from date of issuance) DATE: �iNII'ROVEMENT PERMIT #: ,e�� � .y TAX MAP #: �4 3� PARCEL #: / 7�, OWNER/OWNER'S REPRESENTATIVE: ;�� s o.�I G�.9 �o,� LOCATION/ADDRESS: � S 7 -5 �".�C! .�t G-/�i- � SUBDIVISION NAME: . SECTION OR BLOCK: / � a�t/ �UC 5.S �7% � AUTHORIZATION FOR CONSTRUCTION ISSUED BY: ��..D � ��� AUTHORIZATION CONDITIONS LOT #: � 1. The Wastewater system constniction and installation must meet all of the conditions of the attached site plan and specifications as set forth in Improvements Permit #,a/�z 5. The construction and installation must also meet all 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 Health Department. 3. Any alterations in site or soil conditions (including structure locations) or modification in use, design wastewater flow, or wastewater characteristics as specified in the associated improvement permit and application, may void this authorization and associated pernuts. 4. Conditions: yy,, �T,� Y , /zt ,.� c» a� ,��'�� . /� �D Li� �'s �s.�! Cc'��✓ % d �iZ �/i / �i r7� /'� ,.c. �.n i�� T. . ,.= r il / �i�C�E/G � ` �� �% % L Person Requesting: