A35 44Apaiir.ation Date: I �v�
�lmaunt �ald•
Reca�pt �:
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APPUCATION Ft3R SE3tVIC�S �
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IF T'HE INFORMATIOM IN THE APP�:1CATlOi�l FaR AN IMPRO�lEAAENT PERMIT 1S INCORRE�'i'. F:4t.SIFiE�.
CHANGED OR THE SITE IS ALT�RED THE3N iHE 1MPROVE�IIENT PEiZMTf APID AUTNORIZ�►'f60N TO .
CONSTRUCT SHALL BECOME INVALID. �
1) Pertnit requested b:(Owner/aget�tlprospective ownerj: Doa? � U� y��
Home Phone: �� Address• � ` � �
Business Phone: 9/�i - 55'3� `//z 7 �� 1.,.-.,.. /IL'_ 2� ��3
2) Name and �ddress of carrer�t ownec �A/�t
3) �roperty Description: Lot size: Tawnshlp:
Dice�tions to the property �Induding ro�t names�and
)�
#
4) Proposed lD�e and Stzvcture DescriptIon: answer eaci� af the following q�estians:
a) Proposed _, Existing �, Type of Strucbure: f�{D USF Width: � De�th:
b) Number of Bedrooms: _� Number of �pants or people to be� sen►ed: � -
c) Basemen� Yes No _ Will there be plumbing in #he•basement?�
d) 6arbage Disp�Yes . No ,�, _
5) Water Supply T�e: Privabe �, (new or existing_ j, Public_, Community� . Spring � .
Are any wells on ad�oining praperty? Yes No _ If yes, piease indicate app�aximate locatiori on the
.site pian. �
b� Does your property c�ntain_previousfy idecrtified �urisdictional wetlands? Yes No�
PL�ASE NO'TE THE FOLLOU111NG:
➢ A PLAT OF THE PROPE�2TY OR SiTE PLAiN MUST BE SUBMITfE� W17N THIS APP�iCATtON.
➢ PROP�tTY UNES AiVD CORIdERS MUST BE CLE�►RLY MAR6�D. -,
9 THE PROPOSED LOCATiON OF ALL STRUCTURES i1AUST BE ST�D OR FIAGGE�3.
9 THE SITE MUST �E RE�►DILY ACCESSIBL� FOR AAf EVALUAT]ON BY THE l�E.4i..Ti-i DE�ARTMENT
STAFF.
I hereb� make appiic�tion ta the Person County Health Department for a site e�aluation for the an-siie sewage dispasal
system for the abav�described property. ! agree that the c�ntents of this application are true and represertt the maximum
facili�es to be piac�d on the property. i understand ifi the site is aitered or the intendeii use ct�anges, the permi� sfiali
become irnalid. � � „
or �Le�al Representative
� ' -O�.
Date
PCaD, rev. 06127/02
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7E�m� na-am� �*�'* �as�m�l IE-7L��.11�I�a
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Name �uwov� �:�� �;s . Tag Map # � � .Parcel # u `�
Subdivision � Section/Lot#
� o� >� �a
Authoriz d S te Agent � Date
System components represent approximate�contours only. The contx
beginning the installation to insure that pmpergrade is maintained
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the system prior to
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PGI-�D, rev. 09/12/Ol
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WELL PEItMIT
P�lSE SEE ATTAC�iED Y'Y.AN FOR WELL SITE LAYOU'S
Tax Map #: � J5 Pazce1 #� Township
Applicant }�,.;��� c �� �;s
Subdivision: Section: . Y.ot
Location:� i �4„�r,Z � S�-f 1't'1�C�f��s 1'11�'1 t' J
T�e of Water Sun�lv: �Individual Community Public
Itec�uirements•
Site Approved bp C' -� ► n��� Ja
Groutin.g Approved bp �� �'� �' s
Well LogC��� 1- 2�--�3 _
Well Ta.g_�-Ss � � Z-� -a3
�1L �C'ilt iy,�c .S i `�"v3
xose B��b C�-ss � - Zt�-�
Concxete Slab
s'' ��cna,,..�a 154 �11 �,�)�1 0.-� 1^Z4�._�+3
.� �a.� ��.� Z�,. :�,�
Well Driller. :� <.N� U � 1/ ����1.
Well Approved By: IDate:
'�See Attached Site Sketch'k*
Wells must be 10 feet from propertp lines. �_,
G� Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundafiion.
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Other
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PCHI�, rev. 09/07/01
Barnette Well Drilling Inc � 336 598 9275 01127/03 07:06P P.001
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�wner: �
Locati4n: �_�
Subdivision:
Gr�a���,og
Tax M.apfJ,� ;�; Parcel # �
Lot �
Wcll Construction
D'z�tance From ns�rest �'raperty Line (Minimum 10 fcet) .
Uist3nce from Septic System (Mini�mum 60 feet) _ ' .
Total bcpth«`� f� YieFd: �_ GPM Stati'c Water LeveI: �_ � tt
Watcr Scaring Zoncs: Dcpth � i� �_ ft� ft ft �
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c�:
�cptin: �rGm r to _��._ $. Diametc[' �;,! %�� in
T�rpe: Galvanized Stc;cl' - .
' Weight Thiclrness: �� Height above Ground: � in
Drive Shoc• � Yes No Any problems cncou�tered �uvlule setrin�g casing? Y-cs-�t Nv
If `jres" �ve �`'�eason: _
Grau� _ _
Nea� SaadlCeznez�t Canere'teV Gravel✓Cet�ent ---•
Annuiar Space Width izxchcs Watcr iva Annula�r Spa�cc�-�. Yes No
Method o£ Gxout: Puu�ped Pressrtrc Pour�d- � �epth to �t
Materia�s �Jscd:
No. Ba� �ortland cen�tent Weight vf 1 Bag Pvunc� .
I£mixt�uc (sand, gravei, cuttings) - Ratio to _�
ID plates: _ Yes _ l�0 4 x 4 slab _ Ycs _ No
. D�� �,� Locatian Drawioag
I hereby ce�tify that the above infomlation is conrect and that t�is well was constructed in accordance with re�uiatioA:
set forth by thc Pecaon County Health Dep�nenti
l
Sig�aature of Caatractor _.r,�'��H �1.�� Y� #� Gf �f Date ��1• C' .
. . . n.-� _._.. o� ��cm�
Barnette Well Drilling Inc 336 598 9275 01/27103 07:06P P.003
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