A32 179o�
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�fn�rovements Permit. (EstablishedlRecorded Lot) Reinspection of Existing System (Loan Closing)
ImpFovements Permit (Unrecorded Lot) I Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
_ Bacteria � _ Chemical � _
Permit for New Well
_ Replace Existing Well
_ Pesticide � _ Lead
p '�
. Permit requested by: . - . Dimensions or Proposed Struc�tu�r`e:
wner/prospective owner/agent: � ` - Width: �,� �
�ddress: � �- �P�h'
�}�-(• ��� „�,�� �' � � -�! - 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?
iome Phone #:,...,`'if�� "�s � �310� ' $�� '"'� `�-�,r�; �
3usiness Phone #: � l�cnp u Watf-R— �9�4 - 11(�
Name and addre�s of,current owner: 9. Water supply t}�pe:
' S`��� �4-S B v�/= private h�public ❑ community ❑ spring ❑
- �� Are any wells on adjoining property?Yes ❑ No j�
If so, identify location:
. Pro
Lot size:
. Tax Map#: /t' �?- ��
Parcel#: •
Township: � • -7�� -
�. Directions to property: State Road #& Road
[ames;�tc.
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Number of occupants or people to be served:
l. Type of structure/facility: Proposed:�Existing: Q
type of dwelling:
House: �Mobile Home: L7 Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �_
Garbage Disposal? Yes ❑ No�l
Basement? Yes❑ NobZ1 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 PerSOri COunty Health Depat'tment 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 propecty 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.
� �� � �- `� '
z Signc� Owner � c�Authorized Agent
permit Issued ❑
permit Denied ❑
Plat Observed ❑
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Signature
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Date
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SANDY. LOAMY. Cl/�YE1f. NOTE 2:1 Ml� S �` C� � V U V
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SOIL SERiES
SSl1iTA8LE PSPROYLSIONALLYSU(TADLE U-VNSUiTABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gull�es, wet areas, fill
areas, wells, water bodies, slope patterns, etc.) C:MMIPRO�DOCS�APPSECSM F1NIINCEPC
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'� ' � g 1988
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 been issued.
T� Map # �/4�J �. Parcel # � � '7
Zoning Township �V FO r 1L.
Owner/Contractor G�n � W o 1-��. Date i o-13 - 9 rl
Location/Address
`�� 2 � 5�' (�
Subdivision Name
�11 S
Lot#
SEWAGE SYSTEM SPECIFICATIONS
Lot Area �-I , � O
Mobile Home
# of Bedrooms 3
ti.w.� ..y.. -
s.x.# �vC 1 �5"7
Size of Tank 1 O b Oo,�`�
Size of Pump Tank �111 r'�
Nitrification Line _� � �/OD' X3�
Max Depth Trenches 2�I � �
5Gl-� �-10 P �G 5-�-� pl,���1,.5
Permits may be voided if site is altered or intended use
Well and Septic Layout by � '
Comments: �N,S �S.�L-S ll�
�'1_� _ L � __ �. _ � �,. � . _ �. J_
Date 1�-��� Installed by �. � Approved by
��- / P �02.� 10-13-��i
ell Permit Paid
dividual Semi-Public
�blic Replacement
te Approved ✓
ell Head Approved ✓
�outing Approved 10 .� 2 R=c� �
Comments:
Date $-/9-99 Installed by
SYSTEM SPECIFICATIONS
w•9
Required Slab �
Air Vent ✓
Required Well Log ✓
Well Tag ✓
Approved by.
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
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P�RSON COUNTY ENVIRONMENTAL H�ALTH
Date:�� '� � � .
Owne:. -� C �1901.F'E
Location/Uirections: _
WELL LOG
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SR# - .
Subdivisi�n Namc: � .., ,N � f�.� � ► � mn� S � �
L�t �
Drilling Contractor� �L� CON�
Distancc from Ncarest Properry Linc -
D�stancc from Source of
Pollution � 2. GPM Static Water Level F�
Total Depth: Ft. Yield: • �t.
Ft. Ft Fc._
Water Bearing Zones: t�eptn Z, Ft. Diameter: � ��eS
Casing: Depth: From�_to
TYPE: Steel
. Galvanized Steel '� .
If Steel, does,owner approve: Yes , Hei NAbo ound�_-7nches
Weight• __Thickness: • , �
Drive Shoe: Yes NO �e Casin ? Yes -__ N
Were Problems Encountercd in Setting g
;; "ycs" givc rcasor�: Coricrete
Grout: Type: Neat _ SandjCement
Annular.SpaceWidth 1�__�ches
Water in Annular Spacc: Yes_______ No ��—
Method: Pumped � _ Pressure_____,
Depth: From � to_�_ Ft.
Materials Used: No. Bags Portland Cement�.. Weight of .1 bag______lbs.
to
If mixture (sand, gravel; cuttings) - Rauo: - .
TD T'latcs: Ycs � No ,.
d x d cl ah Yes ✓-_-- N� :
I HEREBY CERTIFY THAT THE ABOVECCORDA1�iCE WITH REGULA ONS SET
THIS V�ELL WAS CONSTRUCTED IN A.
FORTH BY•THE pERSON COUNTY HEALTH DEPARTMENT.
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Signarire of Contract � Datc