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A32 70A�pltcattan Date: �� �7"� L— 7ax Man #• ���� Amount �aid: . C� �–� Re�i t}�#�. Parcal��: � j ',�� . �J�-- ���"��� � J�` ��� �� ,�v� I - - � � � ����- �����,,--� -�-�--�- .��.��. ����s� -;� • �•, �; -�- �� '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 ���.�.� ������ , _, � ������ ��.��mm � ��.�.�. ���.���. �� ���� . ' 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 � h J•1 ' ����� " � J.S.. 1.l.L( /� �1.� V � � � '- � �� �..���� .�r'7laB'n�`amTMn'^'*'*<87CII.��.1L 1LJ1�B.m.J1'�� 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 D� "`"' `� i� a�� r---t I , � �. .. „ . � �v tt� ���- scale: � � ,� �- e�� � 02/96/20�3 08:26 4773i08 � � ����, � � �� �� � � ����� � �'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 ���_�� � ��: �� ., !:'���'''�7G F.7C"�!� � �ii �► , • /1��� • � ♦ , � rlJ����G �' - • ., . ��/l�� i : i , . � ; I.11 .. � �lI4 .. � �� � �� ; �� s . / i ► • ♦ 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 �� ��' �� �c� �c� o��zsro2