A34 1AAnuiication Date: 10-��� -I . Tax Man �: �3 'f
Amoutrt flaid: I �. �G �0 �
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APPL]CA710P1 FOR SHZVIC� ' (� W� I
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!F TI-�E INFaRMAT1�N IN THE APPl.lCAT10N FOR AN IMP4�OVE�AEi�IT Pfl�18R 151NCDRRE�T. FALSiFiE�.
C}�IAWGm. OR THE S1TE IS ALTE�tE�. THE�1 THE IMPRfJVE3NEi�IT P�3ZM1T AND AUTHORfZAT10N TO
CaPASTRUCT SHALL BE�DME IMVALID. -
i) Permii requested b: Ownerlagerrtlpncs�tive own : e Q.. t1 . .
Home Phone: Addr�ss: �bq�
Bt�siness Ptwne:
2) Na�ne and .addr�ss of c�n�ent owner. �YOt�
3) ProQerty De�riQtion; Lat sfre; Townst�ip: Subdivision: Lot�
Directlons ta the property (Indudin road names d n ): �
.
4) pnoposed Use and Struc�ure Descriptton: answer eacfi of the fioilowing questions; �
•• a) Proposed _, Existing Type of Struc.�uB: idth: � De�th: - '�
b) Number �f �edrooms � Numbet of �pants or peopie to be s�ved: � ��
c) Basemert� Yes . No � Wiil there be plumbing in the basement? 1�(�
. d) �arbage DLspasai: Yes , No � . . .
5) Watier SupQiy Type: Private _(new or ems�ng�. P iic . Commun�y . S�ring
, Are any wdls or1 ad�ouung propetty? Yes_ No ,�If yes, please indicate aQQro�imate locatiori on the
'siie pian. .
6� � Do�s your property cantai�i previ�usiy ide�ifi� jurlsdiGtionai wstlands? Y� No� .
PtFASE NOTE THE FaLLOWING: �
➢ A Pl.AT OF THE P4�OPEi2TY OR S1TE PI�W NUST BE SUBMtfTID WRH TNtS APQLICATION.
➢ PROP�TY LlNES AND CaRAIE�S �AUST BE Cl.FARLY NARl�D.. , �
9 THE PROPOSm LOCATION OF ALl. STRUCTUR� MUST BE STAi� OR FiAG�m.
➢ THE S1TE flAUST BE READILY ACt�5S1BLE FflR AN EVALUATiON BY THE HE�ILTH DEi�ART��fT'
STAF�. �
1 hereby maice aQpiication to the Peison CauMy Health De�artrnent for a siie �vaivatiot� for the on-siie sewage dis�.osal
system for the ahove-described proQerty. I agree that the car�tents af this appi'u�tion are true and repre.se�nt the maxunum
faaiiiies to he pla�d on the properiy- I undersiand if the siie is aitere� or the irrtended us� d�anges, t�e permii si�ail
became invalid. �
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� Owner or L.. Re�tive p�
PCSiD. t�v. 061TI102
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`` �� PERSON CO�U'NTY HEALTH DEPARTMENT
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� WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
* .T�ax Map # �3'� Parcel # 1 �4-
Zonin� _ Township , � _
Location/
S.R.#
Subdivision Name Lot#,
La out /* �{y�.� As Installed O ��/ �
Y
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SEWAGE SYSTEM SPECIFICATIONS
0743
epair Lot Area �{�i�+-c- Size of Tank_�'' ��� �`
FD Mobile Home,�/_ Size of u Tank ��
usiness # of Bedrooms�_ Nitri�c���r�� ��� �� S'��
Max Depth Trenches � b"
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered ' te e se c nged.
Well and Septic Layout by W'�
Comments:
�ate Installed by �►�. ��� s Approved by
Well Permit Paid ❑ WELL SYSTEM SPECIFICATIONS
Individual Semi-Pu
Public Replacen
Site Approved
Well Head ved
Comments:
Installed by
Air Vent
Required
We11�
Slab
pproved by,
ev � %
7'his report is based in part on information provided the homeowner o�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 condi[ions 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 environmental 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 01/95 rev.1.0
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STTE PLAN
N .1J �( G� � Tu Map # � � Parcd # �6�
Snb � a Searon/Lot#
�D .
Aurhoazed Staoe Agmt �
S�y� �P�mnT �t'PP�te Q°ma°urs c�p The maa�mrmu�t9ag rhe syearmpaar ao bg�g the msr�at�va m
ras+ue �+tp�rupergndeisma�raiaerL
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WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
T� Map i'T"�
Applicant: _�
Subdivision:
Location:
Parcel
Township:
i ��:: .' �_� _ i�'�
Type of Water 5upply: �Individual
Requirements:
Site Approved By: �-.! s /z/t/by
Grouting Approved By: �/ �z/z/o2/
Well Log: L� � -a -��
Pump Tag:
Well Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Lot #
Community Public
Liner: �
Installed by:
Depth set:
Grouted:
Date: �
f ae�-
�
Water Sample:
3��
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Well Driller: LU'A� ��=�-- ������—
Well Approved by:
****See Attached Site Sketch****
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
Date:
PCHD rev O1/27/04
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