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pd,�.��� �, PERSON COUNTY HEALTH DEPARTMENT
r WELL SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
Tax Map # �J� Parcel # ?� Z
Zoning � ownship
Owner/Contractor Date
Location/Address t �
LI-,on ���P l��sr � I/]�, nv► Y'1(�I . S.R.
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Subd n Name y y `' Lot#
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site i d or intended use changed.
Well and Seprt,ic_ Layout by� /� /�p�,,�./^
(�nmmpnte• IGv�Jo� /I�. /�I iLf' �� %�I/YI %� i �.��/,�%��-i �Sl� . UIY.(,l (,{�/
Date ` v v Installed by Approved by,
WELL SYSTEM SPECIFICATIONS
Individual�_Semi-Public Required Slab
Public Replacement�� Air Vent
Site Approved Required Well Lo�
Well Head Approved Well Tag
Grouting Approved
Comments:
Date Installed by Approved by
This report is based in part on information provided the homeowner or his/her representative in the application submitted for Uus permit. The
enviromnental heatth 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 ihe application. Neither Peison County nor the environmental health specialist wazrants that the septic tarik systetn will
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amiprolpemutsam O 1/95 rev.1.0
ORIGINAL