A32 190.
Amount paid ,56,_O
Receipt l� ' ��_ �3
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Improvements Permit. (Established/Recorded Lot) ._
ImpFovements Permit (Unrecorded Lot) _
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Date
ion of Existing System (Loan Closing)
RepaidReplace existing Septic System
Improvements Permit (Mobile Home Replace) ._ Permit for New Well
Improvements Permit (Addition) ._ Replace Existing Well
a t i'-'.
: _ �� xWater Sample to be Collected.
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. �.w. .y.. .:.. � : .. .... ,. ... ���. ,�<. „
Bacteria _ Chemical Petroleum _ Pesticide
Permit requested by: . v°NO�� "� `J`"� � �r
ner/prospective owner/agent�ro,�.�neC-i�iVe UWt1t
dress: � o T�d Moore � PU Rox C��
�-! �„�,-,I i Q. t`.1 � i I� N C'. ��(�4 I --�
�onald`s�k- (o --Z331 �y....e�
ome Phone #: 3310- 3C�--1�53 �o + si�
usiness Phone #: ��1�- 5�q' �� 4S'�� G y
, _,. . .;
Name and addre�s of:current owner:
. Tax Map#:
Parcel#: _
iv
ion: Lot size: f QC��.
� 1 b i�C
Directions to property: State Road #& Road
ames, �tcf , .
7. Dimensions or Proposed Structure:
�'Width:
_ Lead
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
�hat this sewage disposal system is intended to serve?
Number of occupants or people to be served: �_
9. Water supply type:
private � . public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No �.
If so, identify location:
10. Type of structure/facility: Proposed: C�Existing: Q I
Type of dwelling:
House: ❑ Mobile Hame: � Business: ❑
Type of business: a�
Number of Employees:
Number of bedrooms: ` 4
Garbage Disposal? Yes ❑ No �
Rasement? Yes ❑ No�[ If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORI�IERS 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.
�
Signe� Owner o�Authorized Agent
Permit Issued ❑
Permit Denied ❑
Plat Observed ❑
Signature
-�
_ ,`
Date
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1. SIAPE (%) S S S S
PS PS PS PS
U U U � U
2. SOILTEX7URE(12-361N.) S S S S
(SANDY. LOAMY. CLAYEY. N07E 2:1 CIAI� PS PS PS PS
v u u u
3. SOTL S77tUCTURE (12-161N.) 5 S S S
(MYEY SOtLS) PS PS PS PS
U U U U,
S S S S
d. SOILDEYIFi (IN.) PS p� ps PS
U U U U
S. RESiRICI7VEHOR20NS([N.) S S S S
(1MPERVIOUS STRATA, ROCK) PS PS PS PS
U U U U
6. SOILDRAINAGFIGROUNDWATER S S � S S
(FX7FRNAL & iNiERNAL) PS PS PS PS
U U U U
�. son rEw.�ena�urY s s s s
(PEitCOLOATION RATE� PS PS PS PS
U U U U
E. AVAILABLESPACE 5 S S S.
7S PS PS PS
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9. SiTECLASSiFICA770N(SEEBELO� �s
SOtL SERIES ` �
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S•SUITADLE PSPROVlSIONALLYS11fTAIIlE U•UNSUII'ABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fll
areas, wells, water bodies, slope patterns, etc.� C:MMiPRO�DOCS�APPSEC.S�i FINANCE.PC
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• _ • . �� B 3161
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� ' PERSON COUNTY HEALTH DEPARTMENT
� WELL AND SEWAGE SITE, LOCATION IlVIPRO�EMENT 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.
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Tax Map # A�� Parcel # I�
Zoning Township � h,�
Owner/Contractor
Location/Address
Subdivision Name
Lot#
SEWAGE SYSTEM SPECIFICATIONS
�ir Lot Area �-�(o Size of Tank��
� t� Mobile Home t,� Size of Pump Tank_
ness # of Bedrooms � Nitrification Line�
Max Depth Trenches_
Permits may be voided if site
Well and Septic Layout by
Comments: �
Date - Installed by
ell Permit Paid
Site,Approved_�
Well Head Approved,
Grouting Approvedy
Comments: _ _
or
by.
r—o rI�
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S.R.#
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� WELL SYSTEM SPECIFICATIONS
Semi-Public Required Slab
Replacement Air Vent
Required Well �,og �
✓ Well Tag �/
� 5n � n fl-�'
Date Installed by Approved by
This report is based in part on information provided the homeowaer 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 functio�
satisfactorily in the future or that the water supply will remain potable.
c:\amiprolpermit.sam O1/95 rev.l.l
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Owner. _ `����
Location/Directions:
Subdivision Name:
Drilling Contractor:
PERSON COUNTY ENVIBO2IMENTAL HEALTH
WELL LOG
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llistance from Nearest Properry Line 10 Distance from Source of
Pollution [O Z9 `
Total Dep.th:.�� Ft. Yield: C�_ GPM Static Water Level Ft.
Water Bearing Zones: D�epth �_Ft. t�_F� t30 �� Ft� ��,
Casing: Depch: From C� to L( 2 Ft. Diameter: Inches
TYPE: Steel - Galvanized Steel .�--
If Steel, does owner approve: Y�s No
� Weight: � Thickness: l�k HeighrAbove Ground: 6�i Inches
I}rive Shoe: Yes ✓ No
Were Problems Encountered in Setting the Casing? Yes No ✓
If "yes" gir•e r�ason:
Grout: Type: Neat Sand/Cement ,/ Coricrete
Arulular. Space Width Inches
Water in A�ular Space: Yes No
_ .. Method: Pumped . _ . �Pressure - . � Poured r -�- �. . . . ,, _ ..
Depth: From O to �� Ft. . .
Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs.
If mixtute (sand, gravel; cuttings) - Ratio: � to
:ID Plates: Yes ✓� No � � � � � ' .
�� 4 x 4 slab Yes�—No �
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
T�S WELL VYAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH $y�THE PERS0�1 COi7i�'I'Y HEALTH DEPARTMENT. �
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�S gnaturc of Contractor ate �
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