A34 1100 q
Amount paid ��� d ��� a� � i- 1'GI�
Receipt f� � , � 3-�� Date
. � C��'`���' aPPi,iCATION r(�R S`ERVICES
-.�:. � � � � �s � � - :�<,�; ,��Serivices Requested k =_ �.. � �`�"y , ��� _•� �,��,�''��s�
��R �s.i'� i _ti4: S � YY rvv'rn. �
Improvements Pecmit.(Established/Recocded Lot) .~_ Reinspection of Existin� System (Loan Closing)
mprovemencs Pecmit (Unrecorded Lot) _ Reoair/Replace existing Septic System
Improvements Pecmit (�iobile Home Replace) _ P�;mit for New Well
Improvements Permit (Addition) _ Repiace Existing Weti
Bacteria
` l. Permit requested by:
owner/prospective o�vn�
Address: � � � `(-5
�
c.,
¢
�
�
H
_ Chemical
3
_ Petroleum I _. Pesticide � _ Lead
S��- �7S( `�-p ���
ome Phone tt: � � p
usi�ess Phone r: �7 �S 7y �/ �
7. Dimensions or Prooased Structure:
Width: D
Deoch: � ���%
8. What type (ii any, addicions, expansions, or
replacement is antici�ated to the structure or faciiity
tha[ this s wage disposal system is intended to serve?
I --�
Name and address of c�rrent owner: �-� � 9. Water suoply tyge: 1
� ` private t�: public ❑ community ❑ spring ❑ �
Are any wells on adjoining property?Yes ❑ No i�.— �
5``�o If so, identify location: .
3. Property Description: Lot size: S• 3�
,� �
4. Tax Maprr: S ���
Parcel#: � l
Township: Cu� N: � � � „a,,�,,�--.
5. Directions to property: State Road #& Road
Names,.�tc. , ,� . , ' , D D _�
a
�
I0. Type of structurelfacility: Proposed: ClExisting: Q
Type of dwelling:
House:�l�Iobile Home: Q Business: ❑
Type of business:
,Number of Employees:
� Number of bedrooms: 3
Garbage Disposal? Yes ❑ No �
Basement? Yes �Nofl If so, # of basement fxtures:
�6 Number of occupants or people to be served: � �
CLEARLY STAKE ALL CORI�IERS OF THE PROPERTY AND THE CORNERS �k� �.LL
PROPOSED STRUCTURES.
I hereby make application to the PerSOn County He31th 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 propercy. I understand if the site is altered or the
intended use changes, the pecmit shall become invalid. I understand tha[ before an Improvements Pecmit can b�
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 Depc., this application shall become void and all fees paid forfeited. ,
1,,,�� -2 G-�".�.�
Signcc� Owner or Authorized Agent
- - � T---- -
�
Amount paid ���,��
Receipt !� � iaa� -
� � .! �' � �!
N
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O
�
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U
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a
Improvements Permit.(EstablishedlRecocded Lot)
Improvements Permit (Unrecorded Lot)
1 I- �-� �
Date
�
Reinspection of Existing System (L.oan Cl
_ Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) _ Permit for New Well
Improvements Permit (Addition) _ Replace Existing Well .
� � ` �'
� �� `" �. z,���;:'y�!a`EerSample to be Gollected = �'�" "�
.I
: s ,�.:� *o „�.��„ if '� s r�tr- � Z.�7' . s;^... .t": . <
ai
.,e.,,:a�su.�.._.>..,. .. >.t...i..,., ._.w.:..,.:n. ..;tr ,a,.... . .....:.......:,....,.,..._
'Bacteria Chemical Petroleum _ Pesticide
1. Permit requested by: .
�wner/prospective owner
3
ome Phone #: S �i - 1 �l �
usiness Phone n: 5�7 �S �� ��
7. Dimensions or Proposed Structure:
Width: � D
Depth: � �
_ Lead
8. What type (if any, additions, expansions, or
�j� e� replacement is anticipated to the structure or facility
�—�---- that this s gwage disposal system is intended to serve?
� � ► o � _� 5 -� .�
Name and addre$s of:current owner: �� � 9. Water supply [}'pe:
� priva[e �: public ❑ community ❑ spring �
Are any wells on adjoining property?Yes ❑ No j�-
If so, identify location:
Property Description: Lo[ size:
Tax Map#: . �.�.
Parcel#: �
Township: L' -���
Directions to property:
'
Road # & Road
Number of occupants or people to be served:
10. Type of structurelfacility: Proposed: DExisting: Q I
Type of dwelling:
se:�l�Iobile Home: Q Business: ❑
Ty of business:
�Number of Employees:
Number of bedrooms: �
Garbage Disposal? Yes ❑ No 0'
Basement? Yes �No�I If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PerSOit COunty T�ealth Depai'tment for a site evaluation for the on-site
sewage disposal system for the above described propeccy. I agree that the contents of this application are true
and represent the maximum facilities to be placed on the propeccy. I understand if the site is altered or the
intended use changes, the permit shall become invalid. I understand that before an Improvements Pecmit 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 propetty to the Health Dept. within 60 DAYS aftec the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited. .
�
Si�nc� Owner or Authorized Agent
_ ------ --_._
-------
�.r.�_ . . . .. . . _r�--�—_._ . . .
Amount
�c�ipt
`� »
�
H
0
�
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W
U
�
a
�
a
d
�
¢
H
paid
� D.�� ° °
ll � tQ
0 1�-�'
Bacteria
. Permit requested by: .
wner/prospective owne�
�
Chemical
ome Phone #: � 5 �i— l 79 �
usiness Phone #: S 7.2 ��� a O
Name and address of,cunent owner:
. ,
, Property Des ription: Lot size: •
. Tax Map#:
Parcel#: _
Township:
U
�
Directions to property: State
0
�-)�-�`7
Date
_ Petroleum I _ Pesticide
Dimensions or Proposed Structure:
dth: I �' X �'�
Depth:
Lead
T
�A
�
8. What type (if any, additions, expansions, or i
replacement is anticipated to the structure or facility .
that this ewage disposal system is intended to serve?
� � �
# & Road
9. W ater supply t} pe:
privatef� public❑ community❑ spring❑
Are any wells on adjoining property?Yes ❑ No �
�If so, identify location:
LO ype of structure/facility: Froposed: f�Existing: Q
ype af dwelling:
House: ❑ Mobile Home: C�Business: ❑
Type of business:
Number of Employees: . /
umber of bedrooms: �.—.
arbage Disposal? Yes ❑ No Q�
Basement? Yes❑ NoQ'If so, # of basement fixtures:
6. Number of occupants or people to be served:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORI�IERS OF ALL
PROPOSED STRUC�URF,S•
I hereby make application ro the PersOn COUIIty �ealth Depaxtmen� for a site evalualication ahe t�rue ite
sewage disposal system for the above described property. I agree that the contents of th�s app
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 bc:
issued, I must present a survey plat of the property to the Health Dept. I unders[and that in the event I have not
delivered a survey plat of the propercy to-the Health Dept. wi�hin 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become vo[t� and all fees paid forfeited.
_.2
Sign
or Authorized Agent
perrnit Issued ❑
Permit. Denied ❑
Plat Observed ❑
K+Z��:� �
E,.. , �'c ✓^_�9
Signature Date s z���'� � � � �
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i. SIAPE (�.) S S S S
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(SANDY. LOAMY. MYEY, NOTE 2:1 CLA� S � �►� PS PS PS
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3. SO(I.STRUCfVRE(12•)61N.) S S S '
(QJIYEY SOrt.S) PS S11 /� PS PS PS
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1. SOIL DFST}i (IN.) S S S
PS ��J - � / ►� PS K PS
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S. RES7RICTIVEHORTLONS(iN.) S 5 S - S-
(AiPFRVIWSSLttATA,ROCK) N PS PS PS
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6. SOILDRARiAGF1CR0UNDWATER S S S S
(F�C'[ERNA1.QIIi7ERNn[.1 PS ' nJ� � PS TS PS
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7. SOILPE7tME/1BILJiy ,r�/J S S S
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PS tS PS
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9, SfIE CLASSIFIGTION(SEE BELOV� � �
SOIL SFRIES ' • �
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S-SIJITADLE pSTROYlS10NALLYSUITADI.E l�W1SUITAe[S
RECOMMENDATIONS/COMMENTS: �
SITE CLASSIFZCATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, �ill
areas, wells, water bodies, slope patterns, etc.) C:VIMfPR01DOCSUPPSEC.S�1 FWANCEPC
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
I�
2296
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # ,� � y Parcel #
Zoning Township
Owner/Contractor
Location/Adtiress
Subdivision Name Lot#
La« .-� �
c L .�'Jc e$`
S.R.#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area %��G Size of Tank /�� Qp,rC�%
SFD �- Mobile Home ,✓ Size of Pump Tank N�
Business # of Bedrooms �. Nitrification Line y��( �'
Max Depth Trenches � g–�O'�
Permits may be voided if site is
Well and Septic Layout by
Comments: � Q,,,� n�1Q Q r
or intended u�e chan
Date ����� Installed b}%���vu,� ��� Approved by
Well Permit Paid ❑ WELL SYSTEM SPECIFICATIONS
Site Approved
Well Head Approve
Grouting Approved.
Comments:
_Semi-Public Required Slab
Replacement Air Vent
�equire�etl
—� /1 , Well Ta� .,
Date Installed by Approved by
This report is based in part on information provided the homeowner or his/her
representative i� the application submitted for this permit. The enviroomental
health specialist is not responsible for false or misleading information
contained in the application. The environmental health specialist is also not
responsible for coacealed conditions on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. Neither Person County nor the e�vironmental health
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 O1/95 rev.l.l
1
n 85�03�55"E
344,41
28 �, 94
N 79°52,1
Lt S a W
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D.B. 1 19—
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D.B. 1 17
N 85��c
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Proposed 50�
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