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-�--� PER ON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERNIIT
Tax Map # � �j � Parcel #
Zoning Township r'
Owner/Contractor �Y1n rV YI') �I �-o �1 Date y-�,? v- �1 �
Location/Address N�,<<-�;�,1,�, n'1; i 5, '� � I�- Z"u e.�-�-r�,rtc,� _� l�
� � (�-(�j S.R.#
Subdivision Name Lot# _
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or intended us changed.
Well and Septic L�{out by
Comments: �Vnn�'p(� OrY� /. � Pu�-►-� �.n K GCa,u �� �
Date
by.
Approved
WELL SYSTEM SPECIFICATIONS
-Public IRequired Slab
cement _ Air�Ve�t
T
�(�routi�ig Approved �
Comments:
Date Installed by.
Approved by.
a+;on�
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit The
environtnental health specialist is not responsible for false or misleading info�rnation 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 no� the environmentai health specialist wazrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�permitsam O1/95 rev.1.0
ORIGINAL
o.0 n t p a i d. f Q�j, OU
�ce'ipt .�� '[08(�3
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� APPLICATION FOR SERVICES
S�15 - 9� .
Date
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B acteria Chemical Petroleum Pesticide —
Lea
1. Permit requested by: . �� 7. Dimensions or Proposed Structure:
�wner/prospective owner/agent: � .�rr,� Width: �`
� a,�.o��• i" A h� 3 2��m �� • Depth: S"� _
W
¢
z
ome Phone #: -599 -�'OS'o
8. What type (if any, additions, expansions, or
. replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
:. A'
usiness Phone #: — ' • �
. Name and addre�s of current owner: 9. Water supply t5•pe:
- . � ; , `-' private �j .�public ❑ commur�ity ❑ spring ❑
�� ,� , � Are any wells on adjoining property?Yes ❑ No �j.
���� .� �, Z� S� 3 If so, identify location:, � M � a �'����
. � �,. � .�,.�.__ ��-.�_. , �,.�.�
Lot size:
Tax Map#:
Parcel#: _
Township:,
. Directions to property: State Road #& Road
ames,�tc.
�a,�,�s
Number of occupants or
�
le to be served: �_
10. Type of structure/facility: Proposed: C7Existing: I�i
Type of dwelling:
House: [� Mobile Home: C� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: 7
Garbage Disposal? Yes �l No �
Basement? Yes� Nofl If so, # of basement fixtures:
�
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES. .
I hereby make application to the PeI'sOn County Health DepartmeIIt 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.
igne� Ownec or Authorized Agent
Permit Issued ❑
Permit Denied ❑
Plat Observed ❑
�l. SLOPE(%)
Signature Date
SOIL 7'IX7'IJRE (12-36 INJ
�NDY, LOAMY. CLAYEY. NO"fE 2:1 CL1]7
SOIL S17tUCNRE (12-36 ]N.)
LAYEY SORS)
SOIL DEPTH (IN.)
RESTR1C17VE HORRONS (fN.)
dPERVIOUS STRATA, ROCK)
SOIL DRAINAGFJGROUNDWATER
X7ERNAL k IN7ERNAL)
SOIL PERMFJ�BILiiY
ERCO[AA710N RATE)
AVAILAB(.E SPACE
SITE CLASSIFICA'iION(SEE BEL01t�
4L SERIES
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s s s s
PS PS PS PS
U U U U
S S S S
PS PS PS FS
U U U U
S S S S
PS PS PS PS
U U U U.
S S S S
PS PS PS PS
U U U U
S S S S
PS PS PS PS
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S S S S
PS PS PS PS
U U U U
S S S S
PS PS PS FS
U U U U
S S S S.
PS PS PS PS
U U U U
� S-SUITADLE PSPROVISIONALLYSU1TAIIl,E U•UNSU(I'ABLE �
RECOMMENDATI ONS/COMMENTS :
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, Pill
areas, wells, water bodies, slope patterns� e�C.� C:�AMIPRO�DOCSAPPSEC.SA/ FINANCE.PC
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SI�TE, LOCATION IlVIPROVEMENT 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 6een issued.
Tax Map # � — 3�
Owner/Contractor�
LoIcation/Address �
�it �. � !� � 3-d �r �
Subdivision Name
�
Q
Parcel # 7 �
Township B +.� v
' z fo�t Date $" 30 -r!
5uro A/� ?�5r3 ' N�-/5 �'o �u /� �1 � lIs
� tyo �� �'ks' �. no �id.� S.R.# 1113
Lot# ����; / � d� �i3;�/
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area ,/� c � Size of Tank 0
SFD � Mobile Home Size of Pump Tank �/ .
Business #ofBedrooms 3 NitrificationLine 1k4a 2
Max Depth Trenches l$' " rv 2�
Permits may be voided if site is ltered intended use an,ge %�
Well and Septic Layout by � `1
Comments: T�sf , Q i w 1 �P or � s ei" r a� h o us q— �
s�' a. a �; �. Q e ti� a o►�c C vt ON J- /' 7"d "d Q� '� a�-Q Gc d' '�a u w� e� ,
Date 10 �al—�I'7 Installed by�'� �,.-u-� Approved by cr� �p ,r9 �.�-Y.-.••
Well Permit Paid ❑
Individual
Public
Site Approved
Well Head Approved
Grouting Approved
` `l Comments:
�
��
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WELL $YSTEM
Date � Installed
TIONS Kx ���'N;
�equired Slab
Air Vent
Required Well
Well Tag �
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 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 function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
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