A32 26No. of persons to be serve� Bedrooms 1�3, 4.
Additional appliances to be used: Disposal, dishwasher, was�
machine
��
Recommended• Septic ta
Nitrification line: � /� � �- � � ^'t" ,�� I
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line mus! be inspected aad
approved by a member of the District Healih Departmeni staff before
any portion of the installation is covered.
Date Approved: 8 - yy �
By:
Countersigned
Signe�
Sanitarian
O. David Garvin, M.D., M.P.H.
District Health Officer
<Over)
�
`;�� OTE: M�ke sketch of installation showing location of house, septic tanks, privies, water supplies on
� � adjacent property, etc. Write in measurements in order that installations may be located at later
' date.
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6UGGESTED IN5TALLATION (Da+e ) FINAL INSTAI,LATION (Date )
{ (Road or Street)', (Road or street)
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Amount paid � ` ��� � �
Receipt 11
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Improvements Permit(Established/Recocded Lot)
' Irr►psovements Permit (Unrecorded Lot)
, Improvements Permi[ (Mobile Home Replace3
Improvements Permit (Addition)
Date ��2 �y^� i�
a
Reinspection of Existing System (Loan Closing)
RepaidReplace existing Septic System
PeRnit for New Well
Replace Exiscing Well
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�Permit requested by: .
owner/prospective owner/ag� t:
Address:, - � •--�
Eiome Phone #. `� `
Business Phone #:
� �_ 7. Dimensions or Proposed Scructure:
W idth:
;,, � _ . Depth:
� '
'����� .
8. What rype (if any, additions, expansionS, or
replacement is anticipated to the structure or facility
that this sewage disposal syscem is�-intended to serve?
a e and a res of cucrent owner: 9. Water supply t}pe:
��� ' � private Q . public ❑ community ❑ spring ❑
, Are any wells on adjoining property?Yes ❑ No (�
If so, identify location:
3. Propecty Description: Lot size: /<-t-c-c-v
. Tax Map#: � 3 �
Parcel#: � �
Township: r �
� _.
a¢ S. Directions.to propecty: State Road #& Road
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10. Type of stnicturelfacility: Proposed: DExis[ing: Q i
Type of dwelling: i
House: ❑ Mobile Home: ❑ Business: ❑ �
Type of business: '
Number of Employees:
Number of bedrooms:
Garbage Disposal? Yes � No 0 �
� Basement? Yes❑ Noi� If so, # of basement fixtures: .
6. I�Iumber of occupants or people to be served:
CLEARLY STA� ALL CORNERS OF THE PTtOPERTX AND THE CORNERS �� ALL
PROPOSED STRUCTURES•
I hereby make applicalion to the Pet'SOn COunty �ealth Depaxtment for a site evaluation for the on-si:�
sewage disposal system for the above described property. I agree that the contents of this application are [cue
� 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 t-•
issued, I must present a survey plat of the property to the Health Dep� I understand that in the evenc I have nc
delivered a survey plat of the property to•the Health Dept. wit�in 60 AAYS after the date of the evaluation of
the site by the Health Dept., this application shall become voit3 and a11 fees paid forfetted.
W �
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z Signc� Owner or Authorizcd Agenl
,ernnit Issued ❑
,eTmit Denied Cl
?lat Observedl�
S ignature
�
Date
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��urnM�NllATIONS/COMMENTS: -
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, properly lines, roads, streams, gullies, wet areas, f�1
areas, wells, water bodies, slope patterns� C�C.) � C.1AM[PRUDOCSV�PPSEGS1�1F1NANCEPC
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VVIO� ������
y PERSON CO TY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION Il�'ROVEMENT PERNIIT
Tax Map # Parcel #
Zoning Township 1/
A Ot�1074
Owner/Contractor ' i S� � n� D e %�q _�t r1
Location/Address
� � � �� ,� . S.R.#
Subdivision Name ` Lot#
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SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area Size of Tank �
SFD Mobile Home Size of Pump Tank
Business # of Bedrooms Nitrification Line
Max Depth Trenches
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or intended use changed.
Well and Septic Layout by
Comments:
Date
Installed by
%'2K" �
Approved by
WELL SYSTEM SPECIFICATIONS
In�ividual____�_Semi-Public Required Slab _
Public R lacement Air Vent
Site Approved (� Required Well Lo�
Well Head Approved Well Tag
Grouting Approved
Comments:
Date Installed by.
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
envirorunental health specialist is not responsible for false or misleading information coirtained in the applicatioa 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 environmemal health specialist warrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will retnain potable.� c:�amipro�pem�it.sam O 1/95 rev.1.0
Date: �' � 1 7 '
Owner. � � �,
Location/Directions:
Subdivision N�une:
Drilling Contractor:
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
�s
NSTRUC'TION
SR#
Lot #
Distance from Nearest Properry Line !G Distance from Source of
Pollution /. vc� `
Total Dep.th:. /a�s Ft. Yield:� G1'M Static Water Level- a�Ft.
Water Bearing Zones: Depth �cS Ft. 4� Ft���__Ft���Ft. rc�� '
Casing: Depch: From v to��_Ft. Diameter:_ ��, L/u Inches
TYPE: Steel � Galvanized Steel �
If Steel, does owner approve: Yes No
� Weight: � Thickness: /�� Height�Above Ground: /�/ Inches
Drive Shoe: Yes ;� No .
Were Problems Encountered in Setting the Casing? Yes No �.
Ir "yes" give reason:
Grout: Type: Neat Sand/Cement � Concrete
Annular. Space Width Inches
Water in Annular Space: Yes No
_ .. Method: Pumped . . .._ .Pr:ssure � � � Poured � �._ . . . ,, . :
Depth: From_ C� to �Z'a Ft. � �
Materials Used: No. Bags Ponland Cement Weight of .1 bag_lbs.
Ii mixtuie (sand, gravel; cuttings) - Ratio: co
:ID Plates: Yes �/ No � � •- � .
�� 4 x 4 slab Yes ./ No
I HEREBY CERTIFY THAT THE ABOVE INFORM�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSOv C�Ui1TY HEALTH DEPARTMENT.
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�Signature of Contractor Datc
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