A33 82r
�
Amourit paid . � �'D�
R,eceipt .�� ' f/,p��p
�
w
U
�
a
• ���� �' � � ,
Date
APPLICATION �+OR SERVICES
Bacteria
1. Permit requested by: .
owner/prospective owner
ome Phone #`
usiness Phone
Name aqd,address of,
al
� � a-� �� =
Pesticide
. Dimensions or Proposed Structure:
Width: � �
Lead
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility .
th thi��wage disposal system is intended to serve?
OMt
owner: 9. Water su �c.t�'pe:
private public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No �.
If so, identify location:
Description: Lot size: �" �-�
. Tax Map#: . �
Parcel#: � �
Township: �'. �-� �
� -
ad 5. Directions to property:
� ames �tc.
�
E� i
# & Road
Number of occupants or people to be served:
10. Type of structure/facility: Proposed: DExisting: Q
Type of dwelli :
House: '� Mobile Home: C� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �
Garbage Disposal? Yes
Basement? Yes ❑ No f so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PersOn COunty Health Department 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.
�
A . �
z Signcc� Owner or Authorized Agent
I
Permit Issued ❑ Signature
Permit Denied ❑
Plat Observed ❑
Date _ � ,
;. > FAcrOxs-s��,u.uAnor� :� :,' , ..;.: ,�x�St ...,... °< -i�X2 �..:: ;nx�3 : � Ax�+a... ..
_.:..:..;. . , ...» . ..
1. SLAPE (%) S S S S
PS ps � ps
U U U U
2. SOIL7FXTURE(12-361N.) S S S S
(SANDY, LOAMY. CIAYEY. NO7E 2:1 CLAY) PS PS PS PS
� U U U U
3. SOiLS2RUCTURE(12-361N.) 5 S S S
(MYEY SOILS) PS PS PS PS
U U U U,
g S S S
4. SOtLDEPiN(IN.) PS ps pg PS
� U U U
3. RESTRICTIVE HORtZONS (IN.) S S S S
(UiPERV10US SiRATA, ROCK) PS ps � pS
U U U U
6. SOILDRAINAGFIGROUNDWA'[ER S S S S
(FX7'atNAL & IN7'ERNAL) PS PS PS PS
U U U U
7. SOILPERMEABILIIY S S S S
(PERCOLOA770N RATE� PS PS PS PS
U U U U
8. AVAII,ABLESPACE S S S S.
PS PS PS PS
U U U U
9. SiCECLASSiFICATION(SEEBELOW)
SOIL SERIES
S-SUITADLE PSPROV1S10NALLYSIJITAIII,E U•UNSULTABLE
RECOMMENDATIONS/COMMENTS :
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.� C:V�MTPRO�DOCS�APPSEC.ST1 FINANCE.PC
�
0
� v
"r M
Person County Health Department
Existing SeNage System Report For: ✓ Hobile Home Replacement
Addition
-. - Ir- ��._
i � ' 1 � �. . � �� �
..
� � �� � ,
►� • Ii
Location/Uirections:
Home Phone# � D9.��
BusinessK �
`Pax Map# �
. �. _.._
.
0
Original Permit Located ..
Septic Syste�a Uesigned Eor: _ .
Kesidential l3usiness Other (specifyi
# Bedrooms � # Employees Other
Uate lnstalled ��� - Water supply �
Type o t 5ystem � n Y%%Lj`�/%�
Nitrification Line ��1 �4 ) � 7�X���
Tank Size
, Certified Operator R quired (,�/�
On site wastewater disposal system showes no visually apparent
malfunction on
Yermission is g
According to the attached site plan.
Comments:
, • . :. �IA'//LII��Ir/.��i�� � �r.����.
,L - - - - % � ;
0
: _ � ; . ;� ,,. ...,
� � C�1�1 i _ :i; t1►+�•j' �!� 1 r d. . . �. : s � �,�
;�` '' Persoa County Health Department � i �"
,i ' Well Permit •
._ fi.
,� !/ �
{ DATE ISSUED:• �'�'b,�� DAT$ DRILLCD':����r�jCOUNTY: WSo„� � �
DRILI.ZNG CONTRACTOR6' {Y � � 6� IW/l��W, �J.
NAME ADDRESS
, WELL CONSTRUCTION
Distance from Nearest Prope;ty Lfne Distaace Prom.Source of
Pollutioa .
Tota1 Depthz Ft.' Yield:_y�GPM Static Water Level Ft.
Water Bearing Zones: D Ft. F Ft..
Casings Depth: From � to Ft. Di t �_Inches
TYPE: Steel Galvanized Stee1�. '
' if Steel, does owner app�QQ Yes No
Weight: Thickness:' QQ Height Above Ground: Inches
Driva Shoe: Yes ` No
Were Problems Encountered in Setting the Casing? Yes No_
if •yes' give reason: /
Grout: Type: Neat Sa ement Concrete
Aanular Space Width Inches
Water.ia Annular Space: Yes No
!lethod: Pumped • Pre e Poured�
Depth: Fromi' to � Ft. :
Materials Used ..-sNa. 8ags-Portland Cement Weight of
1 bag� ' lbs:"..` : ,
If mixture (sand :-g�c�rel, cuttings) - Ratio: to
ID.Piates: Yes V No
4 x 4 slab Yes� No
• DRILLS�IG LOG
De th _ `
Prom To F rm tioa Descri tion
� � w
� � -
I HEREBY.CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AN •_THAT THIS
WELL WAS CONSTRQCTED IN ACCORDANCE.W REGUI:IITIONS SETs, RTIi 8Y THE
PERSON COONTY HOARD OF SEALTH. PE�O�� �F,T�i]'_niREE EARS.
�r �i �
Date
� � ��
o ta anuae
�
Sanitarian•s Signature Date Completed
Sketch xell locatioa on reverse side.
� �� -� ;,__ �.Y ` 4',
j�
� , . '�� ���` .
,,. ..
, �
__ ._ .. .. . . ','"-...... -�
. _'. : `: _ _
. _ _ -- .. . �
.. . � . _.
._.. Y-/
. . � � .., . ..: �
. -' •
�ri _
—_
1 , _ � .
i �.( _ , _ f'
; � �; . .: - �,�,
� x � � . . _ N.
.
.
_ V
. . .. ..
• � .. . . .. _ .
. .: .
i. . _ . -� � � - . � ' . ..
i.. _ .. .. . ..,', . � .. '� , .� . , ,-..
� ' , ... . . ' .. -
� . ... .. ..: .. . . . . . . -.- . ' ' -
i ` • _
, .. .__. .. ........ ...__. ... �
. . _ ..... c:...,. . ..,.. _. : .
i:, . . _. . . , . ._ _
PERSON COUNTY HEALTH DEPARTMENT
SEWAGE DISPOSpL
IMPROVE!lENTS PERMIT O.
/� (� Issu�atee �—1 " �
Y� O /� f ! + �
� � Owner: . b. IlAi � � rh�
/� Locatio� -
�J Septic Tank Contractor:
:' � � Building Contractor: �
: � ,_� Water Supply: Private Public
.:.� �_:... �
�-��� f All wells�should be 100 ft. from sewer system.
Lot Size: � r
Sewage Disposal F cil'ti�sc o. edrooms /
Size of tank: Nitrification�linee' , '�
/'
Other disposal facility� r
Water supply and sewage disposal facilities location, installation and
protectiion must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be
maintained by owner in such a,manner as not to create a public health
hazard. Septic tank and nitrification liae t4UST-BE INSPECTED AND
APPROVED BY A MEMSER OE THE PERSON CO. HEALTH DEPARTMENT STAFF BEFORE
ANY' PORTION OF THE INSTALLATION` IS CO\/ERED AND PUT��D� USE.y TEiI� ,
PERMIT VOID AFTER 3 YEARS. �� � f �
`' � ' ,. `� ! � 1J y .
; ,.�:,� ; ;r;- , M �� .
� � � j����f .:��; . .i'��r '
Data Well Approved: � Signed :�; n< '�f �'�!�
gY, �..-San tarian - .
Date Sewaga Disposal J��jroved:
131,..- counter- ;
gy; signed
(Owner or his representative)
Certificata of Completion
'Date Approved: � u � � BY=
Sanitarian
(Over)
Location of well and sewage disposal facilities sketched on back.
' ' -� � � �!, � � ��� �•7 . �.'✓��a.y,,i'
i:, /-'' ':, `'�/,' .`�:� 4 f � .
e
i
_