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A34 111
timihunt paid 37.�A0 q-14- ,� Receipt .�6 ' � �4 Date Q��-'� ��'� � � nnT T•re•rrriN F(1R �F,RVICES � O � , . ; :,, . �.... . , . .., . : ,: : .. _ _ Improvements Permit.(Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing) Impxovements Permit (Unrecorded Lot) _ RepaidReplace existing Septic System Improvements Permit (Mobile Home Replace) � Permit for New Well Improvements Permit (Addition) _ Replace Existing Well >; � � , �� fl ; �` ,'S�'ater Sample :to be Collected: �; . . . s,�' �.-. � <� ..�. . ....V,. ._„y _ . ._„ w .. ,< . .. __. �. . .. v,� . , .. .Bacteria Chem�cal ._ Petroleum _ Pesticide _. Lead 1. Permit requested by: . owner/prospective owner/agent: Address: • -�- � �- � ' � �L W � Home Phone #: � g a usiness Phone #: 2. Name and address of current ow e '--� -e S � ��� ,,�,,. 0 4� � ' �X-W � � �tl\ � 3. Property Description: Lot size: _ w � z 7. Dimensions or Proposed Structure: Width: 1`} �� � 6 Deoth: 8. What type (if any, additions, expansions, or replacement is anticipated to the structure or facility that this sewage disposal system is intended to serve? 9. Water su t5•pe: ,� 2'R-. _ private public ❑ community ❑ spring ❑ � Are any wells on adjoining property?Yes ❑ No,�. 1 l� ��U � If so, identify location: Tax Map#: � 3 � Parcel#: � � Township: - Directions to property: State Road #& Road ames,�tc. ��� �W� , � ' ��e_ � �'b �'� o y, 5 5 \'� Number of occupants or people to be served: 0. Type of structure/facility: Proposed: �Existing: Q I Type of dwelling: , House: ❑ Mobile Hanne: Business: ❑ Type of business: Number of Employees: Number of bedrooms: � Garbage Disposal? Yes ❑ No 0 IBasement? Yes ❑ No� 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 PerSon COunty �-Iealth 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. � c�J.�,�J �� ��/���� � ,/ ��i,� � c� �' ` -� Owner or Authorized Agent Permit Issued ❑ Permit Denied ❑ Plat Observed ❑ J -�,R Signature _ Date ,� � � �� �./�� ' , �. � � O � � , _'_ � ---____. __' , J' . / / �J SLOPE(%) SOIL TEX7IJRE ( I 2•361N.) WDY. LOAMY. CIAYEY. NO'IE 2:1 CLAI� SOTL S7TtUCTURE (12-ib IN.) LAYEY SOR.S) SOIL DEPIH ( W.) RFSIRICJIV E HORIZONS (iN.) +1PERVIOUS STRATA, ROCK) SOIL DRAINAG&GROUNDWATER XTFANAL Q WTERNAL) so��,�Bt� ERCO[AA770N RAT� AVA2LABl.B SPACE SCCE CLASSiFICA710N(SEE HELOW) )IL SERIES S PS U S U � � PS � �� � S PS U S PS U S PS U S PS U S PS U� S $ PS PS PS U U i S S � �� � � � S S�5 l��;�� S 1` m PS ` I l��- ;1 S S PS PS U U S S S PS PS PS U V U S S S PS PS PS V U U s s PS PS Y U U S S S PS PS S U U 0 L S•SUITADLE PS-PROVISIONALLYSUITAIII,E U-UNSUITABLE � � RECOMMENDATIONS/COMMENTS: w 2 � v� o,, ��-..�QQ.�ry SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope patterns� etC.� C:IAMIPRO�DOCMPPSEC.SA1 FWANCE.PC � . :Y:-��• _ _ � . . .:. . : � � � ._ :. ' ', � " . . 1)` rj��� . � : . ' .. . ... . - . .. .� � .�-. �_ .. . � �amer d'.Mary:Wolker ' �,L�+Q� . _ ,Q�.. . " _ ' �. e: 27s = �sa;. rso � . . � _ .. N__� 8 - _. � . . . .. . . � �� •2 � . � , • .'` � N -� - . `a f� . • - �• . . � . . ' . � . � � . c�� fv . . `. •�• • .. - L � r . .. / . . . . . . � .� •' ' ° � - ' � `• � ' • .,11, 1' I '' 1 ���� 11 �UI� , � , p� . ' . � \ �, g i L �, u ►� ns�°1 - �- . . . � • � . . � .•�,:. . = • .1 ,� ' 8�� n ib� � -cn . . . . ~ "� - . . � • .. t - . t� �� �i � - / . . • � . , � ' ' . _ -. . ' . : ' . • ('�i/s�� Ol( U ¢�� � � � • + • ; . _. . - rt n � _C - . . . - • � : � . .o�. . v �. _ . . - . -- �b�-Lz-�. . . _ . .. � :?� _ . . . : . . z�bl - �s .. � - . � :00 �ac. ,� � ont�o� . . : � . . • . . D�a � — s�d �'-2� �;' . : . . � ---�' �orner . . � � . � r'� � . z� � . . -� John T..• BrQndon :: bh-�-� �� � � . � �° . �= . . . _ . ��� . . � � .�r. : � s��� h�i��.�� ����d � � . -. ._� _ o - �,.� . . - , . . - - . . . . _ . �:� - � �-A�. = � � .� . � . . . � � ' ' , . . � . �i/ �� ' ' M ' ' . . . _ . . . � . ' . . " � ' . ' . .. : � . ! . . . 4 ' .. . � ,_ . • - .. � ' . . . , .. • .N. � ' .. . ' . � .. . + _ � � � , �. � - � - � � �oritro! .. � � � _ -� � � - ,Ccirner -j - - � ., ' - -' '� � ti a�a•°° > ": : _ . - Y. ..: z �r ... _ . . `� . - Y , ;��. : �, ` � ,���j,�,� . � - ' .' , •� + - R� � .,t F _ ; Y'� '" •' '� ��� . � .�. '�%. � � �4 *. .. .,- t .. �r. .-,;rx �..�_. ': _ , , - .;,r ,.��,�' . - . � � y ..• ` i.. �p+ , . h Y _•,i' S--� Y � + -, - r :� Y . • .�- �. ' ;. '. s '0 +� i� ���{"' i S'S :• . � � � _ � }� r� , �.'" • -6, .� a .r ��. �/� . ! :F . C . . f,'^"' _ . �4 = �rA �t " .s - ,,,1 .. `� sI•�n . . ,��_ . � ,� V • ,7. •'j'� �.r�=- . . . ' . ' + _ 3 . . _ .. - �., _ � . `i'• ,�, ' ia�' ' . ... . �. . '.. `' . . . . . . � •._ . . . ... r .N^ - � � ,'�=. �Jumes • W. .Walker . � , � _ a , � , �.: ; _ s r: y � � , '. .`D B .218-5�9 � � � L �� � �� ' : , - *� :� ��` . �� �� _ . � � �0�e -. - ,..'. � . . "- . * t . � _ ' ' / ' " O� ��5 • • , �e i - - ;.. • _ . , � �.. '0$ =' . ' < � '' f . . . ` � . OQ�S ' ��. ' �� � ` � - �` � + ". s..�re t". _ . µ ' \' . ' ' � � ' '.. • e< .. 9 �$ ' � ' - • ai':-s•;:r,."' � ' ,� J :H' - n N.itr Y- _ . � � '' _ .. . _ ' ���y�..,. . . , . . . • . .,. ' . f l t „� � �]i"v:i-. . . � _ ' . � - �� • • . . r � . • . . �yy �^' � �}v;cs���.p�� .i,: . 1 t : � . . . . . '__- + ' _ ' . _.�h �'��'}.�5� 7�;.�: ' ' ' ' . i- .� s. 'g'.'+- � . ' . . _ - .. . =-��� ;-f =': .r-:: R�c►^. - _ • : -. :, . �• • • ''•' �' ` ~ . •, ..,. ' _ �,>yi,,..�-• .._. •^ ., a . � • ^ � ' J: 'l� � M y .�/ �}. T; IY f _ r v• •r _«�• . �-'•a� yk�. , ..•; s . � . }:: . _` :�. M , t ` � :� �i =. � . ., � � j ' �.. , :ioiin':;.. -$r M ,�'�''{ . , .�' rf .. :Ny � ' •K � 4 � "�,C y.� �j . . � t �` . .�' '7 . ` . � �� . . . � -:Ji- `+'-;,�'z�a' � ;1 �� ii .:3�sa ',+�►•. . ��.;-i. y r: ' ",a - � �� ` `+ �� -?���; - � - w ✓ . . .- - - � � W � a ��I � .� ... ....... �I PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT B 2�55 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 # � � � � Zoning OwnerlContractor p�. E' Location/Address YY1C�' ,e.e 5 i'% Parcel # � � � Township � r� n; na n. � W t� c� 5G�2 �� eS W� l IC�C" ate g- I Z— �'r �� Subdivision Name Lot# S.R.# 133 �_ SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area �. C� �C_ Size of Tank ).��Q SFD 1� Mobile Home �� Size of Pump Tank Business # of Bedrooms�_ Nitrification Line � 7d� u3 � Max Depth Trenches �� � "��-( �' Permits may be voided if sit ' red or Well and Septic�yout by an _Jl; �, _ D� � ` Date (o—C.{ — Q G� Installed by Approved Well Permit Paid ❑ WELL SYSTEM SPECIFICATIONS Site . Well Date Semi-Public Installed by Required Slab Air Vent Required ell Well Tag _ � Approved by. This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. The 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 application. Neither Persoa County nor the eavironmental 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 � � . � � ` ' � tk 3 � • �- :^ ;i 1�>..'!;M k ���� �.�,�h L.6a����. ' i•.-l+f§,. .. ..\ , . ; �" . ' . �.. � . ... - .. . `''e � �. i �,c� jt, L i'r �� ' ��f �Ct-�' R�• �'; t ,.tlya'� � � < sr� �, A! � � �, . t �•�..+. � . �.N ��•`kQ i�n';'� y . w s� � � � � ' 4 Y 1 ,,� . . ' ' . . 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