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Improvements Permit (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing)
Improvements Permit (Unrecorded Lot) Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) Permit for New Well
Improvements Permit (Addition) Replace Existing Well
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` ` Water Saitnple to be Collecfed
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Bacteria l � Chemica� _ F�tra!eum _ Pesticide _. Lead
1. Permit r.,quested by:
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6l��• �- tiia- �; 5 7. Dimensions or Proposed Structure:
� m -� ` ) Width:
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Phone#: �'-9lD--� �`�~/0�0°(
,ss Phone #:._J=�lD--597-58� 3
Name and address of cunent owner:
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. Tax MaF
Parcel#:
iption: Lot size: 3`� � ��
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a¢ 5. Directions to property: State Road #& Road
� ames, etc.
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8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage dis osal system is intended to serve?
�a ..� Sp l� �,.� ` � 2 -�� � � ! � �
9. Water su�ly t}•pe:
private �public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes �o ❑
If so, identify Iocation: C� �;-� P_ Ho „S e_
10. Type of structure/facility: Proposed: C�xisting: ❑
Type of dwelling: �,�
House: ❑ Mobile Home: L� Business: ❑
Type of business:
Number of Employees:
RcQ Number of bedrooms: 3"'S��
IGaroage Disposai? Yes ❑ �vo u
Basement? Yes ❑ No C�f so, # of basement fixtures:
!6. Number of occupants or people to be served: � �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CQR1�::S �� tiLL
, PROPOSED STRUCTURES.
I hereby make application to the Pei'SOn COunty Health Depat'tment 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 invaiid. I understand that before an Improvements Permit can bc
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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Signed Owner or Authorized Agent
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. � ERSON COUNTY HEAT TH ��FAR � MENT
WELL TD SEWAGE SITE, LOCATION IlV�RUVEMENT PERMIT
Tax Map # �� Parcel # � Q
Zoning Township O D �, P
Owner/Contractor �e � m�! $ IZe� ee D��/iS�Date 1 J��
Location/Address C't? t� i�� t1 �� n/p� D- c a s�r,
V � � � S.R.# / �
Subdi rision Name
i,ot#
F,s Installed
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A001218
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SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area aCycs Size of Tank
SFD Mobile Home Size of Pump Tank
Business # of Bedrooms � Nitrification Line
Max Depth Trench'�
Permit Void after 60 months. Permit Void if not in compliance with
Permits may be voided if site is al d or 'nte ded use changed.
Well and Septic Layout by
Comments:
N��
regulations. Li u e. ��lv�'
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Date /z-/z_ Installed by��, ��-�� Approved by Gi/.,�-� .t� �-+-�
1 v � Gt _ G +� �-LUN`-
te Approved_k
ell Head Approved
-outing Approved_
Comments:
WELI, SYSTEM SPECIFICATIONS
Semi-Public Required Slab _
Replacement Air Vent
� Required Well Lo�
� Well Tag
�-
Date
This report is baseci in part on infocmation provided the homeowner or lusmer representauve m tne appncanon suomiuea ior ws pernu�. i ne
environmental health specialist is not responsible for false or misleading Wocmation 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 &om false or misleading
statecnents provided to him in the application Neither Person County nor the environmental health specialist wazrants that the septic tank system wilt
continue to function satisfadorily in the future or that the water supply will remain potable. c:�amipto�pecmitsam Ol/95 rev.1.0
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Date: a��'= 4 '
' 'Owner. � � a.
Location/Directio s: �
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Subdivision Nvne:
Drilling Cona-actor:
PERSON COUNTY EI�iVIROtZMENTAL HEALTH
WELL LOG
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SR#
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Uistance from Nearest Property Line �v Distance fro„7 Source of
Pollution f � `
Total Dep.th: !� Ft. Yield: �/b GPM Static ti�/���T Level a�'"' Ft.
Water Bearing Zones: Depth �'0 Ft. B__ v___F� F� F�,
Casing: Depch: From U to!_�o ___Fc. Diameter:_,�_��hes
T�PE: Steel - Galvanized Steel r-
If Steel, does owner approve: Yes No
Weight: � Thickness: /� ,Heig,hrAbove Ground:=jnches
Drive Shoe: Yes ✓ No
Were Problems Encountered in Setting the Casing? yes j�o ,�
If "yes" gi�e r�ason:
Grout: Type: Neat Sand/Cement_ ✓ Concrete
Annular Space Width_ ?- 3 Inches
Water in Armular Space: Yes_______ No ✓
_ .. hlethod: Pumped .__ -�, �Pr�ssure � - Poured�/ � . . �, - .
Depth: From O to �. � Ft. � �
Materials Used: No. Bags Portland Cement y Weight of .1 bag �i'�lbs.
If mixture (sand, gravel; cuttings) - Ratio:_� to /
�ID Plates: Yes ✓ No ' � .. �
�� 4 x 4 slab Yes�—No '
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
� T�S WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIDNS SET
FORZ'H By�THE PERSO�I C�LiJTX HEALTH DEPARTMENT.
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�Signaturc of Contractor Datc
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