A33 67�
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� A 0� 33
PERSON COUNT� HEALTH DEP.A.RTMENT
WELL AND SEWAGE SITE, LOCATION IN�ROVEMENT PERMIT
Tax Map # �} 33 Parcel # ��7
Zoning Township ;
Owner/Contractor '�v ic�v� W� I( i m S Da o?Lo
Location/Address l.S3R �ohesus CFi,
Subdivision Name
Layout
� Perr�-�-t- wr�-lY4er. -t�o altot�
mob� le 1�ome a►. b� Qs
�}�t,c�n c,� i�f-� no G�nSi�
'{-o e x�5'¢'` ►-.� 5 y �e�n
/
�
s.x.# , 3a3
Lot# � —
As Installed
� �
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area Size of Tank ;�'� �
SFD Mobile Home Size of Pump Tank /�
Business # of Bedrooms_ 'Z Nitrification Line ac;5�-,,� c,
Max Depth Trenches
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or ' de u e hange
Well and Septic Layout by -�
Comments: „
Date
� WELL SYSTE PECIFICA IONS
Individu Semi-Public _ Re ' d Slab _ �
�bli Replacem r� �r Vent _
Appro Required W
ell He Approved Well �
�
Date I" ed by Approv
This report is based in part on Wormation provided the homeowner or his/her representative in the application submi or this pemtit The
envuonmental health specialist is not responsible for false or misleading infonnation contained in the application. The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in Uvs repoR that may have resulted from false or misleading
statements provided to him in the application Neither Person County nor the environmental health specialist wacrants that the septic tan]c syscem wil1
continue to fundion satisfactorily in the future or that the water supply will remain potable. c:4vnipro�pemutsam O1/95 rev.1.0
ORIGINAL