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Improvements Permit (EstabIished/Recorded Lot) ._ Reinspection of Existing System (L.oan Closing)
Improvements Permit (Unrecorded Lot) _ RepaidReplace existing Septic System
Improvements Permit (Mobile Home Replace) ___. Permit for New Well
Improvements Permit (Addition) _ReplaceExisting Well
_ Bacteria � _ Chemical
I . Permit requested by:
owner/prospective owner/agent �Q.
Address: �-�• � �3 � � ��
w
�
ome Phone #: � `77- '�'''
usiness Phone #: �99-
Name and address of current owner:
.
3. Property Description: Lot size:
4. Tax Map##: � 3 q'
� Parcel#: `1 �
_ Petroleum I • Pesticide � _ Lead
� ` 7. Dimensions or Proposed Structure: b,
2Cl !a Width: X 80 �, �.2�� x�
' � Depth:
Directions to property: State Road #& Road
ames, etc.
�e
Number of occupants or
��
le to 4e served:
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
tha[ this sewage disposal system is in[ended to serve?
9. Wate�r s ply ty pe:
private�d public❑ community❑ spring❑
Are an welis on adjoining property?Yes ❑ No �
Y
�If so, identify location:
10. Type of structurelfacility: Proposed: DExisting: ❑
Type of dwelling: �.,/
House: ❑ Mobile Home: U✓ Business: ❑
Type of business:
Number of Employees:
Number of bedrooms:
Garbage Disposal? Yes No ❑
Basement? Yes ❑ No G�If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE COIZNERS OF ALL
'PROPOSED STRUCTURES. �
I hereby make application to the Person Coullty Health Depaxtment for a site evaluation for the on-site
sewage disposal system for the above described propetcy. 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 undecstand 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.
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PER�ON COUNTY HEALTH DEP��TMENT
'�� WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # � �arcel #
Zoning ��i�� "l�ownship ' n a v�►
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Subdivision N
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SEW G SY T M SPECIFICAT NS
Repair Lot Area � G� Size of Tank �gf
SFD Mobile Home Size of Pump Tank �►
Business # of Bedrooms Nitrification Line � 3' �-
Max Depth Trenches �, ��
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations. �''y '`""
Permits ma be voided if site is altered or inte ded us chan ed. �4 vry �%
y g p�w. �
Well and Septic Layout by '
Comments: �w`� �"� �
w�. �'. n ► � r, I n � r _ n
� ,c_�4..�(��,b,z
Date /6–��–��7 Installed by
Vell Permit Paid � �VELL SYSTEM SPECIFICATIONS
�dividual��Semi-Public Required Slab �
ublic Replacement Air Vent
ite Approved Required Well
Jell Head Approved Well Tag
Comments:
�
�-ttiwv--
Date��.� Installed by �, h�/a Jl►-. 0.T'–� Approved bX _ Y'
This repoR is based in part on information provided the homeowner or his/her representative in the applicat' submitted for this permit. e
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 applicadon. Neither Person County nor the environmental hea(th 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 01/95 rev.1.0
r ! z-
Dat f Inspection
l�s( �'P�C
PERSON COUNTY HEALTH DEPARTMENT
'ACE WASTEWATER SYSTEllZ MQNI7CORING REPORT
o � � � �
Syste Inst ltati�n Date Type ax Map Pazcel #
�� � �
Property Address
Ir�structions: Check yes or no far appro�riate items anc3 explain inspace provided for remarks and
comments. If an it�m is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate
hy "N" and expiain. Note that this monitoring form is not totaliy inclusive for all systems. All mainte�ance
and monitoring items specifisd in the pernut are to be carried out.
IN5PECTION RESULTS
COLLECTION SYSTEM:
Evidence of leaks 7
Tank risers accessible, free of
infilhati�n snd sut'ace water diverted 7
Septic tank needs pumping 7
Inches of solids:
Septic tank fil±er cleaned ?
FsFFLUENT DOSING SYSTRM:
Req�sired pumps present & fi�nctianal ?
High w�ater alarm operatiag progerly ?
Floats, valves, ete. in good condition ?
Contral panel & components in good
aondition ? .
Ef�'.uent firee of excess solids 7
Inches of sbfi�s(pampi�ose tznk):
Elapsed time readings ?
Counter readings ?
Drawdowr. rate:
YES / NO
❑ � ❑�
❑ � ❑ '"
❑ / !� _
� � ❑
❑ � ❑
❑ � ❑
❑ � L� / v
❑ � �
DISPOSAL F�EI.D:
Evidence of cffluent surfacing 7 ❑
Evidenca of effluent ponding in trenches ?❑
Surface water effectively divsrted ? ❑
Di��ersio:is/sw�les properly maintained ? ❑
�Jegetatire cover mainiained 4 ❑
Protected from irafr"ic/unauthurized uses ? �
Distribution devices in good coudition ?❑
Field free of settled or !ow are�s 7 ❑
/
/
/
/
/
/
PRE3�LiRE DISTRIBUT'ION SYSTEIYI:
Turnups/cleanouts/vatves/taps intact &
accessible ? ❑ �
Pressure head properly adjusted ? ❑ �
COMPLIANCE:
Campliant
Non-compliant
Needs �Zaint�nance
AI)l�i 1 IpNEiL CONIvl"Elv 1 S:
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❑ �
�
REMARKS
.
Date:_a-/O -�'Fr •
Owner. _ �
Location/Directions:
�l rY,, l e
Subdivision �N� e:
Drilling Contractor:
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
�
�
Uistance from Nearest Properry Line �D _ Du�ce frc,m Source of
Pollution ,/o� '
Total Depth: ��'� Ft. Yield: � GPM Static ti�ate; I_evel_�i� �=�,
Water Bearing Zones: Depth I Yf Ft. F� Fc. F�
Casing: Depth: From��to�Ft. Diameter: Inches
TYPE: �teel � Galvanized Steel
IF Steel, does owner approve: Yes No
� Weight: � Thickness: /£SF's .Height�Above Ground: � �i Inches
Drive Shoe: Yes ✓ No .
Were Problems Encouncered in Setting the Casing? Yes No ✓
IC "yes" give r�ason:
Grout: Type: Neat Sand/Cement_ ✓ Concrete
Annular Space Width Inches —
Water in A.�ular Space: Yes No
- -. Method: Pumped . � -Pressure � - p ura � /1____�_ . . ,, -
Depth: From O to__ a c� Ft. , --
Materials Used; No. Bags Portland Cemenc _ Weight of .1 bag__lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
�ID Plates: Yes� No � � .. � .
�� 4 x 4 slab Yes No �
I HEREBY CERTIFY THAT THE ABOVE INF4RMATION IS CORRECT AND THAT
T�S WELL WAS CONSTRUCTED II�T ACCORDANCE WITH REGULATIONS SET
FORTH By�THE PERSO�t C�ui�'1'Y HEALTH DEPA. TMENT.
�; .�� __-
��
�Signaturc o Contractor p�c� �