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PERSON COUNTY HE�I,TH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
Tax Map # ,Q� 2 Parcel # S
Zoning Township �Q ,{- e � �
Owner/Contractor �-�- ('� � � lP..�� �� Date % - /� -q Q
Location/Address 3S 1 2v �, `� (�Qr v,� ___
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SFD
Lot Area
#
AGE SYSTEM SPECIFICATIONS
Size of Tank
m ize of ump Ta l�
�o s. Nitr cat n Line
�� Permit Void after 6 nths. �ermit Void if not�it�liance with zoning
� Permits may be voided if site i altered or intended use changed.
� Well and Septic Layout by
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� Comments:
Date /-/!� -� Installed by L7�'���N e� Approved by
G7!'ou PG % ^ �d� � �lu...0 v+---
WELL SYST SPECIFICATIONS
Individual 1/Semi-Public Required Slab
Public Replacement L� Air Vent
Site Approved Required Well Lo� _
Well Head Approved Well Tag
Grouting Approved
Comments: ��r OI(��,25°%U� � � �—�
Date Installed by Approved by
This report is based in part on infomiation provided the homeowner or his/her representative in the application submitted for this pertnit. The
environtnental health specialist is not responsible for false or misleading infocmation contained in the application The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in this repoR that may have resulted from false or misleading
statements provided to him in the application. Neither Pecson County nor the endvonmental health specialist wazrants that the septic tank system will
continue to function satisfadorily in the future or that the water supply will remain potable. c:�amipro�pecmit.sam Ol/95 rev.1.0
_. ORIGINAL