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PERSON COUNTY HEALTH DEPAIZTMENT �
WELL AND SEWAGE SITE, LOCATION IlVII'ROVEMENT PERMIT • ''
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Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorazat�on for vrast� vt�n�er s�stem construction
has been issued.
Tax Map # � .3 �� Parcel # �
Zoning Township -�
Owner/Contracto � �-, � Date , _
Location/Address S/' / � ' S " /.�`' v
e � , � ;' - � �,�- S.R.#
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS _
Repair Lot Area �U <t
SFD Mobile Home
Business # of Bedrooms�
/V1 �'� � !��
Permits may be voided if site is altered
Well and Septic La ou by
COIriTTIeritS:
. � � .
Date j/- /3 - y� Installed by_
Well Permit Paid ' WELL
� Individual ✓ Semi-P ic
Public acemen
Site Approved
� Well Head A nroved ,
Size of Tank / �� (/(/ �'��
Size of Pump Tank � N ��i—
Nitrification Line �170 ?C.3 �
Max Depth Trenches � ( � �
�ld �..��n�Y�-
� e se c anged �jJ,� �.�'-��e ��� �l7/3�'lL
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�uired Slab
Air Vent
Required ell Log
Well a�
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Date ' Installed by�� 1 I�,.P Gr2.(-f' Approved by.
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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 praperty 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 remai� potable.
c:\amipro\permit.sam O1/95 rev.l.l
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See P.C, g_g�_2 &
See P.B. 9-127 �
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� A�v D.B. 141-263cher. Sr.
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�� `� Property Line Agreed Upo� i
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\ � �� ��� ;! �3S?y,8ruce C. Butcher c,c ���iam Long �
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Dudle � �''q� hfO p�
D.B. y w& Lois M. Pruitt � 3 c��� c��'
209-488
Control Corner
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'� � ��� `� � - PPLICATI F R ERVICE � - ' '
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` ' ' ' ' ' Services Requestec�.
. ; ,. : ,.:: .; _ . .. <
Improvements Permit (EstablishedlRecorded Lot) ._ Reinspection of Existing System (Loan Closing)
�mpFovements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Repair/Replace existing Septic System
,_ Permit for New Well
� Improvements Permit (Addition) I._ Replace Existing Well � �
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� Home Phone #: _
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usiness Phone #: S��^_�%S�,S�
7. Dimensions or Proposed Structure:
�
Width:
Depth:
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?
and address of_c rrent owner: 9. Water su�ply ty�pe:
� private ��public ❑ community ❑ spring ❑
�; � - Are any wells on adjoining property?Yes �o �_
,,p ti� � Z('� '3 _ If so, identify location:
. Property Description: Lot size:
Tax Map#:
Parcel#:
. Directions to property: State Road #& Road
f ames,�tc.
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Number of occunants or people to be served: �_
10. Type of structure/facility: Proposed: �Existing: Q
Type of dwelling: ,�,,/
House: ❑ Mobile Home:1�G1 Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: .�% — Z
Garbage Disposal? Yes ❑ No �
Basement? Yes ❑ Nofl 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 Pet'sOn CouRty Health Depai'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 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.
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Owner or Authorized
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Permit Issued.L7 , Signature �Date (� �`7'"�� • ' .
Permit Denied ❑
Plat Observed ❑ , , _
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" .' FACI'ORS-STlEEVALUA770N. , > ' . ` X1t&1:E � ' !.��42. .. .:; > AREA3 ; l��d
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I SLOPE(%) 5 S S S
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2. SOILTFXTURE(12-36INJ
(SANDY, LOAMY. CLAYEY. NOTE 2:l CCAY) PS ! PS %�J v PS PS
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3. SOIL.S7TtUCfURE(12-161N.) S S S S
(CL.AYEYSOiLS) PS s� PS �yJ�fj� PS PS
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�. SOILDEP7'H(INJ 5 5 S S
PS 3� �1 PS u PS PS
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5. RFSTRIC77VEHORIZONS(TNJ S S S S
(AIPERVIOUS STRATA. ROCK) PS PS �0 PS PS
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6. SOILDRAINAGFIGROUNDWATER S S S 5
�F�CCERNpL k Q�7�ERf7pL) PS PS � n PS PS
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'7. SOIL PERMEAB1LTfY S � S S S
(PERCOLOATION RA7E) PS �� ,.. PS � PS PS
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8. AVAI[,ABLE SPACE S • S S
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9. SifECLASSiFICA170N(SEEBELOW) SlJ/�C�C
SO1L SERIES S
SSUITADLE PS-PROVISIONALLYSUITAIILE U•UNSUITADLE
RECOMMENDATI ONS/COMMENTS :
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, eCC.� C:WMiPRO�DOCS\APPSEC.SMFINANCE.PC
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P�RSON COUNTY ENVIRONMENTAL II�ALTH
W�LL LOG
Date: ��1 � �� '
Owner: �
Location/Directions:
►
SR# � 0
Subdi�»��on Name: Lut �#
Drilling Contractor: uK�a uuil.ul�msa.� irJ �
WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollution
Total.Dep.th: Ft. Yield: GPM Static Water Level Ft.
Water Bearing Zones: Depth Ft. F� Ft� Ft.
Casing: I�epth: From � to,�Ft: Diai:ieter: � Inches
TYPE:
Grout:
Steel � Galvanized Stee] ✓
If Steel, does owner approve: Yes No
Weight: Thickness: • � Height Above Ground: Inches
Drive Shoe: Yes No . � �
Were Problems Encountered in Setting the Casing? Yes No
;i "ycs" give reason:
Type: Neat SandJCement Coricrete
Annular. Space Width � Z. Inches
Water in Armular Space: Yes No
Method: Pumped Pressure � Poui ed �� �
D�pth: From O to 2.0 Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes '� No � �
4 x 4 slab Yes ✓ No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON COUNTY HEALTH DEPARTMENT.
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Signature of Concract - Date
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