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PERSON CO Y HEALTH D PARTMENT
A 001007
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERNIIT g3�� 3��
�Tax Map # � � Parcel # ' �
Zoning Township (�% , P
Owner/Contractor S�-�� � G/-� Date 7��"
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n vi � r.�{� o�i Srt #' I 3�� S.R.# .�.�
Subdivision Name Lot# ��
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SEWAGE SYSTEM SPECIFICATIONS �.
Repair Lot Area Size of Tank
SFD Mobile Home Size of Pump Tank
Business # of Bedrooms Nitrification Line
Max Depth Trenches
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Pernuts m��ay be voiyed if yte is alte ��,nte�ied'u cl�e hanged.
Well La out b /' ��� � !lti•��
Comments:
Date Installed by
_ �
by,
' � WELL SYSTEM SPECIFICATIONS
d 'dual Semi-Public Required Slab
�b ic Replaceme t Air Vent t/
te Approved � Required Well Lo� 1/
ell Head Approved Well Tag t/
�outing Approved� � °
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Comments:
Date
Installed by
Tivs repbrt is based in part on information provided the homeowner or his/her represecrtative in the applica�ion submitted for th�s permit The
environmental health specialist is not responsible for false or misleading infortnation contained in the application The environmental health specialist
is also not responsible for concealcd conditions on the property or for statements in this repoR that may havo resulted from false or misleading
statements provided to him in the apptication. Neither Person County nor the environmental health specialist wazrants that the septic tanlc system will
continue to function satisfactorily in the future or that the water supply will remain potable.• c:�amipro�permitsam O 1/95 rev.1.0