A32 70A�pltcattan Date: �� �7"� L— 7ax Man #• ����
Amount �aid: . C� �–�
Re�i t}�#�. Parcal��: �
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'1� TH� INFORMATION IN THE �,PPL• ICATIORI FaR AN IMPROVEAl1ENT PERIIAR 18� INCORRE�'T, Pa4LS1F1Et1
CHANGED. OR THE SITE 15 AL'fERED. TNEAI THE 1NAPIi�VEiIAEl�IT PERM�'f AND �►UTHORIZJ�,i1�P1 TO .
O 9 IJGT 3�►L 8 CD�6E i ALI . ` G� .-,.s "�
�ij Perrnit rsque�ted by: (own�entlprospecttva owner):� � � /�_s e . ��k«
Hame Phone: �� y- � j y� Address: i o z o f/G ��:, s��.. ��
Business Phone: 3�• S�•d 9c� N���/� _�,.�//s, yc z� s� �
2� Name and audddeess af cucr�nt a�nmer;
3} Pra�erty De�crl�tion: Lat size: Tawnshlp: Subdlvisian: Ln# #
Direc�ons bo the property (lnduding road names•and numbee�s): r-f. ��lv%!� �,�i s �// .{�t /d
. 3��1 .., . • /< � ; t ._ f . .
4) Propo�d Us�.and Structure D�s�riptl�n: answer eaci� af the fopowing que�tions. �
� a) Proposed _, Exlsting . TyQ� o�f Struc�ure: � Width: ' I7epth:,_„_.�
b) Num6er af �edroams: Number of oc�upants or peoQle to be� served: -
c) Basement Yes . No Wial there be plumbing in #he•basemeni?
d) 6ari�age �ispasal: Ye� � Na —
5) W�ter �pl�'ij�pe: Privabe �(new � ar exlsting_,j, Puplic_, Commwilty�_,, SP�9 �
Are any wells an adjalning ProPeriy? Yes No _ If yes, pl�ase indlcate app�axlmats IacatIori on ifi�
.site pi�rt. •
' 6� Does yaur prop�rty contatta_previousty Identi�d jwrtssdicti�nal wetlands? Yes No
- 1 el� �, . • 1
➢ A PL�T O� TWE PROPE�tTY OR 31TE PLAN i18U�'f BE SUBMCfTE� VRi11i�i THIS APF�R.ICJ�17lON.
➢ PliOPERTY LlNES AND CORNERS 119U9T 8E CLEARLY MARl�D. •,
➢ THE PROPOSED LOC�4TION OF ALL. 8TRUCTURES flilU9T BE STAd� OR FLAGGEi3.
9 THE SITE MU�T BE RE�4DILY ACCESSIBL� FOR AN EVAWA77�1N BY 7HE HEAILTH DEPARTOdEi�l'T
STAF�. � � �
I hereby make appiic�tion ta the Person Caunty Health Department for a siie evaluatIon fior the on-site sewaga �ispas�i.
system fw the ab�ve-descrihed property. l agree that tfle carrtents af this applicatian are hue and represet�t the maximu�.
f�ciii�es�to he placad on the property. I understand ifi the s�te is alte�ed ar the intended use changes, the permit shali
becnme lrnalld. •
IZ-z�-�Z --
Cwner o 1 Representat3ve � Qate
PC'r!C], tev: D61271p2
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' P�t�.SE SEE �'�."I'AC3�EI) I'�.AlV FOlt WEI.I. SI'I'aE I.AA3�OU'�
Tax Map #: �� 1'azce! # � Township
APPlican�
Subdivisiori: Section: Lot
�
� `-1 \ +'ii � j Y'r' � �-1/
.
'I'y,�e of Water Sum�ole: � Indiviclual Community Public
Rec�uirements• � �
Site Approved bp
Grouting A roved bp '���i
Well Log
Well Ta.g,
Air Vent �
Hose B�
Concrete Slab
We11 Driller. � \ `�°"��
Well �pprovet�. �p: Date•
'�°5ee Attacfliesi Site Sketch�*
Wells must be 10 feet from propertp lines.
Wells must be 100 feet from septic spstems.
Wells must be at least 25 feet from anp building founda.rion.
O�er conditions: -
PCfID, rev. 09/07/01
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Si� ��Tc� �e� l
Name (_�11'�S ���� Tax Map #�Parcel # 7�
Subdi n �'���-Section/Lot#
� �
0
uthorized State Agent + S.,,r Date
System components represent approximate �contours only. The contracto must, flag the system prior to
beginning the i tallation to insure that propergrade is maintained
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scale: �
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02/96/20�3 08:26 4773i08
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�'s3�ra�-�a�am���zCa'�.m� �'"��o.�.n'��a
HUDSON WELL CO
Dri!Ifer D � � +� ,
C� ra� �:� n y N.. � r�i�t e,�
D•,�t�r Qrillec! !
Well Lag
Ownez�• (�� �i � Q��'.�je2. 7ax. Ma� A',�ZParcel ,# ��
Locat�on: L�4t�eDcF .L-� � ll t -a -i lD.�Cj I�Au.1yS� ns �00 P�C�
Subdivision: tot # ��
"Well Construci�ivn
Distance Fzozn nearest Property Line (Minimum �0 feet) _��d ��
Distance fxoua. Septic Systez�t (Minimum b0 feet) ��p(��
'�'otal Depth: �� ft Yield: G Static Water Leve1:
Watec Bearing Zones: Depth � /�o � ft $
ft
Caeing: $ �
Dcpth: From �^ to _ �� ft. Diameter: Ce � xn
Typc: Galvauizcd Stcei ✓
"Wcight:o0l 'Thickness: .�,�'� Height abQve Gxound: /o? in
Drive Skoe: ,_ � Yes No Az�y probl�us encountered w�uile setting c:asing? �Yes �/ro
If "yes" give zesson: �_ .
FaGE 01
Grout:
Neat: S�d/Cement Concreie GraveUCexne��t
Annular Space Wzdth inches Watex in Annular Space Yes No
Method of Grout: Pumped _� Pressure Poured �� Depth �, to Ft.
Msteri�ls Used: �
No. Bags �'ortland cement Weight of 1 Bag _� Pounds
If mixture (sand, gravei, curtings) — Ratio to
ID plates: _ Ye�s „` No 4 x 4 slab __ Xes _ No
Dt�lling Log �..ocatlon Drawing
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I hereby eertify that t11e above informatian is cvrxect and that this well was co�zstructed in accord�ce wzth regulatiet�s
set ;Forth by tb.e Person County Healtla Iacpartznez�t.
Sigaature of Contxactnr C�- ID # �% Aste ,l �� ��' ��
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