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Improvements Permit (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing)
Improvements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) �rmit for New Well
Improvements Permit (Addition) _ Replace Existing Well
Permit requested by:
ner/nrosnective own�
ome Phone #:�'I a � 5`9 9-- r� Y��'
usiness Phone #: .S 9 y—� i/ l
Name and address
7. Dimensions or Proposed Structure: (,,,�i'
Width: v/' S' �, �V'�
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?
owner: l�a.�.�'a.� 9. Water supply type:
private Ir�'public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No ❑
If so, identify location:
Description: Lot size:
Tax Map#:
Parcel#:
. Directions to property: State Road #& Road
Tames, etc.
(�ia .[�' C� il, ��.� %� d a-c.P ! 3 3
. Number of occupants or people to be served:
10. Type of structure/facility: Proposed: DExisting: C�'
Type of dw,�el,�li g:
House: Lf Mobile Home: ❑ Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: Z
Garbage Disposal? Yes ❑ No �
Basement? Yes ❑ No C�7f so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PersOn COunty Health Department 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.
Jignea vwner �r r�u�iiui►c,cu r�go�►�
Permit Issued ❑
Permit Deni�d ❑
Plat Observe� ❑ - --�
Signature
Date
:� •
_ ___.
FeICTORS•SII`E EVALUATIQN ARE4 i O.REA 2:;:' AftEA 3 AREA 4:
_.. _._ :
,
1. SLOPE (9b) S S S S
PS PS PS PS
U U U U
2. SOIL 7'EXNRE (12-36 IN.) S S S ' S
(SANDY, LOAMY, CLAYEY, N07E 2:1 CLA1� PS PS PS PS
U U U U
3. SOIL STRUCTURE (12-36 IN.) S S S S
(CLAYEY SOILS) PS PS PS PS
U U U U
4. SOIL DEPtH (IN.) S S S S
PS PS PS PS
U U U U
5. RESTRIC7'[VE HORIZONS (IN.) S S S S
(iMPERVIOUS SiRATA. ROCK) PS PS PS PS
U U U U
6. SOILDRAINAGE/GROUNDWA7ER S S S S
(EXTERNAL & INTERNAL) PS PS PS PS
U U U U
7. SOIL PERDIEABILITY S S S S
(PERCOLOAT'[ON RATE) PS PS PS PS
U U U U
8. AVAILABLE SPACE S S S S
PS PS PS PS
U U U U
9. SITECLASSiFICATION(SEEBEI.OW)
SOIL SERIES
S-SUITABLE PSPROVISiONALLY SUITA6LE U-UNSUITABLE
K�C(�MMENDATIONS/COMMENTS:
SI'TE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.) C:WNIPRO�DOCS�APPSEC.SM FINANCE.PC
-.- �,'33 �
. �' PERSON COUNTY HEALTH DEPARTMENT
� WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # � 3 S� Parcel # � �
.
'' Zoning Township
Owner/Contractor D e �-Z (�, - 1 S�
Location/Address �a� i��� � �1ct��2- � s/�, /33..�-� s2#/33y
Q���n �5 : `j ;, Yi� �S
�� ubdiv�sion Na
�1'N �VI1�'..�'7����,� I� �.Z (,�� iC /��.R.
Lot# ��
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Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits ma be voided if site is altered or �' n�f d se c n ed.
Well and S ptic Layout by //'/./�,!/J��Gt/1��
Comments:
Installed by�'���'�(,���Approved by.
Well Permit Paid ' WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab
Public Re acement Air Vent
Site Approved_� Required Well Log i%
Well Head Approved Well Tag !/
Grouting Approved - c
n.� 3 t �
Scl{
70
Comments:
.� , ' i� -
Date Installed by .� %�, ��l �1'��- Approved by
This repoR 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 property or for statements in this report that may have resulted from false or
misleading statements provided to him in the applicadon. 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\permitsam 01/95 rev.1.0
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1'L•'1tSUN CUUN'1'Y LNVI1tONMLN'1'AL (1L•'AL'1'll
WELL LOG
Date: ���'�• �'q6
Owner�C� U- �
Location/Directions:
SR#
�
Subdivision Namc: _ , �� . . • Lot #
Drilling Contractor: (1N K1►�) W ILLI AMSO�J .t1JG •
WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollution
Tota1 Dep.th: _ Ft. Yield: � GPM Static Water Level Ft.
Water Bearing Zones: De th Ft. F� F� Ft.
Casing: Depth: From � to Ft. � Diameter: � Inches
TYPE: Steel � Galvanized Steel ✓
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� "y cs" givc :•cason:
Grout: Type: Neat Sand/Cement Coricrete
Annular Space Width ,2. Inches
Water in Annular Space: Yes No
Me.thod: Pumped . Pressure Foured � ✓ .. . .
Depth: From � to � 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 C4NSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON COUNTY HEALTH DEPARTMENT.
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Signature of Contrac ,.�- Date
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