A32 96No. of persons to be served Bedrooms 1, 2,G74.
Additional appliances to be used: Disposal, dishwasher, washing
machine � � � �
Recommended: Septic ta I
Nitrification line: ��r� g I
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line must be inspected and
approved by a member of the District Health Department staff before
any portion of the installation is covered.
Countersigned
Signed
Sanitarian
O. David Garvin, M.D.; M.P.ii.
District Health Officer
(Over)
�
_ NOTE: Make 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.
d _ BUG3ESTED INSTALLATION (Dat�+ )
(Aoad or Street)
FINAL INSTALLATION (Date )
(Road or Street)
��
J
eoaiication Oate: � a6"b0
�,niount Paid• , � D �
R� .
Tax Map #:
Pa�l #:
Person CauntY Heaith Departtne�t
Environmental Health Section
. APPIlCATION FOR SERVICES .
IF THE INFBRMATtON IN THE APPl1CATION FOR�AN IMPROVEiIAENT PERMIT IS FALSIFlE�. CHANGED. OR THE SiTE lS
ALTERED. THEN�TFIE IIlAPROVEIUIE�IT PERMIT AND AUTHORIZATTON TO CONSTRUCT SHALL BECOME INVALID.
1) Permit requested hy: (Owner/agent/prospecSve owne�: S 0.1u� C,� 0.1P i,S
Home Phone: '7�'� ��7 '7f'j � Addres� 1^Q t�JJJ �' c/�
Business Phone• � 0 � �
,
2) Name and addcess of cu�terrt owner:
3) Property DescrIF"__. . _. _.�_ � �T_.�..,_.
Di�tions ta the
�) Pmpcsed Use and Struc�.�re Descriptlom answer eac3� af the foUowing qaes�cns:
a? �P� 4 Existtng �
b) S�dc Bu�7t ❑. Moduiar �. Single Wide Q. Double Wide a
c) Number of 8edrooms: cn Number of oax�Qants a� peopte to be secved:
e) Basementi Yes Q Nc l7 If yes� # of basement fi�u�
� fl Garbage Oisposa� Yes Q No ❑
� Oimensia�s�of Propased Strucnure: VVidth: Depth:
� Watec SupPh/ TYPe: private a�new a o� e�as�n9 a�, Pu�c a. G� a. s�ns a.
Are a�ry we8s on adjoining propetty? Yes � No a If yes, tocation
6j Please I�dicate Desired Syst�em Type: (systema can be ranloed in orde� of your pcaference)
Conventtonal NlodiHed Comenttonal _ Aitemativ�e Innovative
Other (specifyj:
CLEARLY STAKE ALL CORNER3 AND LINES OF THE PROPERiY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTUiiES.
PLEASE A'fTACH SURVEY PLAT OR S1TE PLAN TO THIS APPlSCAT[ON
I heroby make applicatio� to the Person Couniy Health Dep�artrnent tor a sita evaluatlon tor the on-site sewage diaPosal system fa
the above-descs�bed propeity. l agree that the co�tents of this application are true and �t tha ma�dmum ta�tles to b�
placed on the P�P�Y. ! understand ifilhe sits is alt�ered acthe �rtended use c.t►angea. the pem� shaU become invaad. I un�cstan�
that as ap�iic�nt, I am tespons�le far identifying and ma�idn9 P�Y iines. comess and matdng the �ibe ac�le for ttu
personnei of the Persan Cauity Heatth Department to condud their evaluaiioas. l tu�erstand that 1 am r� ��9 ��
Heaithh D t ff my pro contains am► wetlat�ds as designabed blf � A�1f ���teers-
f
� �� —O
Owne�' or Legal Represerttattve Date
1 [
,�ti`i� ,�
; Q��.r�
,
PERSON COUN"rY HEAL'1,H D�PARTMENT
A 1540
�, WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map #_��� Parcel # 9�c
Zoning Township � /� D F"1
Owner/c:uniia�tut ,�� C�.v�S Date � a 7-� __
Location/Address_f�Z_� � an Gu�.r�s 2oad �0.C,<< �aU �'S �d .
�a?CoS i'S an C� S.R.#
I Subdivision Name_N / 1� Lot#
�
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�
a
t.�y�Ut
� �DME
w���
� f 'j 0'
7 z- 5
� � � ��
L L
0 �
T �
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,��`` �p� ����
V .�,I����N
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ns t�nea
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area /. 0 i4G 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 ' is a e pr ' tended use changed.
Well and Septic Layout by
Comments: Ktto i� t. � 1 lOD' _Fr�rn S� o�� � N rc �
Date
Installed by
Approved by
WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab
Public Replacement Air Vent
Site Approved Required Well Lo� 3� 4F 5-r'1-Da
Well Head Approved Well Tag
Grouting Approved JN K ��9'aD
Comments:
Date Installed by
Approved by
This report is based in part on infonnation provided the homeowner or his/her representative in the application submitted for this pem�it. The
environmental 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 Person CounTy nor the environmental health specialist warrants that the septic tank system will
continue to fundion satisfactorily in the future or that the water supply will remain potable.
ORIGINAL
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