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A32 18200 �i Amount paid 37�, �— ���� U Receipt li � (, � • , Date � H O � .� � W U � a ua � z �'�-�''"" nenair/Realace existing Sept�c 5ystem RPniare Fxistin� Well 7. Dimensions or Proposed Structure: W idth: � � T,e..►�.. ,� l n lo " 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? �. _ �,�e 9. W a er supply t5 pe: private . public ❑ community ❑ spri g❑ Are any wells on adjoining property?Yes� No �. If so, identify location: 10. Type of structurelfacility: Proposed: �Existing: Type of dwelling: House: � Mobile Home:� Business: ❑ Type of business: Number of Employees: 2 Number of bedrooms: _ Garbage Disposal? Yes ❑ Nob Basement? Yes ❑ No'0 If so, # of basement fixte CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF PROPOSED S'TRUCTURES. I hereby make application to the PerS0I1 COunty He31th Depat't h econtent of th s applic tion ahe �n sewage disposal system for the above described property. I agree that t 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 nderstand that in the event hav� issued, I must present a survey plat of the property to the Health Dept. I u delivered a survey plat of the propercy to the Health Dept. within 60 DAYS after the date of the evaluation the site by the Health Dept., this application shall become void and all fees paid forfeited. SiQn O ner or Authorized Agent � . . . __ . ... .. . . . - Y � , _ N '01"29'19'W ""' d �� /}�(Ir� /}�(/]y�1 ` ;y, 4� ��:�,r � � _ . ,, �'� ' . � Vi.�V�Vi , . . , R1 .. ) •'r ( Rt . . � / . : 2: F . \ I l J ' � . � . ' . , . .I . . � f�i � �� � � � .. 0 Q � - � � � . . � . 1 . 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'� t�.. ,��w .� � ,{ r�� ' 7 '..Y. a jl . /l,:i r ♦.F.+'-w v. j ti1: �.. � �..` � _,{.., .. � `y:,. ��.!�� �/�,�.�. � .�Q�. ti.� a�- ;;�4`� .Ne! _t/bt.»�, t'� ,..� ,�-.,, Y'r- "'.,f. 1 r�, i?'*'� r=Tkti. t ,t'' A �a�.� �S �;1 ��c,��)� �•�''i* . , . ., . � " � � r .' : 3' �'•. .✓ 1 r�. n �` F .rs��. .t� � �S -..tY_. �i. � ,c� -� ��" . . ���^•A' ' tl,.. .i�., � �'�Stit,x. ..ti y,�('�';*��� W�'.v 5 '?i'� a. y.s�N ,� A * �- � �, # a �,•�.:� � �. �-:{S-, � � � . . . . ` � ., . , O ~r . _r , Ty�'r �•�: �. . , � 4.. . ,. , ,. . � �. �`.'t . ��'� - . . , f � .., . ;'.� s.f;.. ..i cih4.`� , •` � '� �. �♦ +."r x �> �r :��.�,. � T } .0 Y r:��e�'b $4, .� 4, �'v •'� � � w U � a � � '- . PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT 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 # � 3 � Zoning Owner/Contractor ,hp�,{�� S (� Locat'on/Address ��,�(,� � p,{�'1 i( �` 7 � r� .n .Lno ,., � � -!_,.� 1J n � .11 Subdivision Name Parcel #_ Township . � _ ,.. _ . � SEWAGE SYSTEM SPECIFICATIONS Lot Area �p . o� � Size of Tank L l� 1/ Mobile Home �/ Size of Pump Tank � # of Bedrooms � Nitrification Line� Permits may be voided if site is altered or i Well and Sept' Layout by Comments: ��,(?�f� D �3V� �' by. Max Depth Trenches �cH � Pv� nded use changed. Approved by Well Permit Paid l.� WELL SYSTEM SPECIFICATIONS Individual 1/ Semi-Public Required Slab _ Public Replacement Air Vent Site Approved Required Well Log Well Head Approved Well Tag Grouting Approved Comments: � Date Installed by Approved by S.R.# I 1 1 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 co�tained 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 Cou�ty 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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