A40 215a
�11/16/1998 16:27 5971799 PLANNING AND ZONING
AmounL paia� p�}, D _ ••��•�• /
Receipt �l �ry2�s{ I
'��� ariPLICATION � � v
n
Zmprovcments Fermit (Estab;ished/Recorded Ldt)
Imnravements Permit (Unro�:vrded Lot)
k�provemcnts 1'ermit (Mab�.�e Home Rcplace) _
Improvernents Permit (Add;�.ion)
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1 1-1 ��q �
D�k�
,_ Reinspection of Existing System (Loan �los
_,_,,. RcpaidRcplace existing Septic Systern
� Pennit for New Weli
�„ l�eplace Exiscing Well
` . Pcrmit requesttd by: . 7. Dimensipns or Proposed 5tructure:
owncr/prospective owner/agaut; �� �� ► �-m •�' ` � Width:
Addcess: 1. (o �' � � �-� � \ �� Depth: a
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$, What'type (if any, additions, expansions, or
replaccment is anticipatcd to thc structurc or facility
that this sewage disposal system is intendcd to serve?
c�mc Phone #: ► q ���.=.L� 17
usinass Phonc #: �l 1� „� ~a�33
�. Name and address of,cur.,�:nt owner: 9. Water �upply type:
' —"s i Cc�. o b� N SB-�" privatc �(. public �J cammunity ❑ spring I�
`—`- ,- a.' Are any wclls on adjoining Qroperty'�Y�s�l No j�.
I�l,t �..� �\ ISnK►� .9 �►s Du h QM If so, identify laatiot�: Sw� »
. Property D
. Tax Map#;
Farccl#: _
T�...�..�:...
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: L�: c siza•
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. Directions to propccty: atat� Road #& Raad
f ames,,zic.
�.�.�. r ��- i s � - .S
ype of stcucturr,/facility: Proposed: �xisting: C
Type af dwelling: �/
Hous�: L7 Mobiie Home: lY1 ausiness: ❑
TyQe af busincss: �
Number af Employecs:�
Number of bedrovms; �
Garbage L}isposal? Yes �❑� o �
$asement? Yes E� NoLY�f so, # of b�semont fixture
(6. Numbcr of occupants �:�r peaQie ta be served: � -
/i1
CLEARLY STA,�;E AY.�, CUR�YtS OF THE PROFERTY Ai�iD TkIE C4RN��LS OF AL
PROPOSED STRUCI.'rJRES.
I hercby make applicatio:� to tha �'erson County Health �epaxtment for a sice evaluation for chc on-s;
sewage disposal system '.'�r tho �bove des�ribed property. I agr�e that che contettts t�f this applic�tion aca ttue
and represent the maxin�am �acilitics to be placed an tha pcoperty. I understand if the site is altercd or the
intcndcd use changes� tl:.o pctmit shall bocorne invalid. I undcrstand thac b�fore an Improvements Parmit can
issucd, I must prasent a;�urvey plst of the propcRy to the I�calth Aep� I undcrstand chat in ihe evcnt I have n
dclivcrcd a survcy plat �:�f the proptRy tq the Health Dept. within bU nAXS aftcr the datc oE ihc evalu�tion of
the site by the Health ��ept.� this gpplication shall become void aad all fces paid forfeitcd.
0
Signa� Owncr
. ,� -- .
Ag�nc
M
� 1►- � PERSON COUNTY HEALTH DEPARTMENT
.�r"�r� SEWAGE DISPOSAL
ZMPROVEHENTS PERMIT NO.
,'p Is,S.ue Date: � �- �
� � J 1 C-C� t O I�li�S
� Owner: �
Location: y �� "r,�
Y ns)
Septic Tank Contractor: u�
Building Contractor:
� Water Supply: Private�Public
�
All wells should be 100 ft. from sewer system.
Lot Size: v � ! f
Sevage Disposal Fac ities• No. bedrooms
Size of tank: ����� Nitrification line:
Other disposal facili
Water supply and sewage disposal facilities location, installation and
protectiion must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be
maintained by owner in such a manner as not to create a public health
hazard. Septic tank and nitrification line t9UST BE INSPECTED AND
APPROVED SY A MEMBER OF THE PERSON CO. HEALTH DEPARTMENT STAFF SEFORE
ANY PORTION OF THE INSTALLATION IS COVERED AND PUT TO USE. THIS
PERMZT VOID AFTER 3 YEARS.
� ��1ii-�
Date Well Approved: Signe
gy; Sanitarian
Date Sewage Disposal Approved:_
Counter-
By: signed
(Owner or hi representative
Certificate of Completion
Date Approved:� � � By: 1 ` ��
a itaria
(Over)
Location of well and sewage disposal facilities sketched on back.
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person County NealEh Department
L %` Well Permit
DATE ISSUED: � � -Q � DATE DRILLED:� ��d�.i COUNTY: ✓ �Y.l�
OWNER: � - �� ROAD/STREgT; '
ADDRESS: ��. ✓�y l4nL �,
DRILLING CONTRACTOR: �t�,�J..h,f�i�% �� ��i
NAME ADDRESS
WELL CONSTRUCTION
Distance from Nearest Property Linc'��Distance from Source of
Pollution (� Q- , :r�
Total Depth: Ft. Yield:�_GPM Static Water Level Ft.
Water Bearing 2o es: Depth��_Ft Ft.- �,l,1,�`L Ft. Ft.
Casing: Depth: From_(�_to Ft. Diameter: �,'r Inches
TYPE: Steel Galvani2ed Steel
If Steel, does owner approve: Yes No
Weight:��_Thickness:�_�eight Above Ground:� nches
Orive Shoe: Yes d. 7/,n�o
Were Problems Encountered in Setting the Casing? Yes_No_��
If 'yes' give re�son:
Grout: Type: Neat �� Sand/Cement Concrete
Annular Space Width � Inches
, Water in Annular Space: Yes No ��
Hethod: Pumped� pressure Poured L�
Depth: From to �_�t,
Materials U ed: No. Bags Portland Cement_ l� Weight of
1 bag��ibs. --�'_._
If mixture (S�d. 4ravel, cuttings) - Ratio:�to�_
ID Plates: Yes V No
4 x 4 slab Yes�— No
Z HEREBY CERTIFY THAT THE ABOVE ZNFORMATION ZS CORRECT AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE W7TH REGULATIONS SET FORTH BY THE
PERSON COUNTY BOARD UF HEALTH. PERM T VOID AFTER THREE YEARS,�� '
. , _�� / l3L�.3.�. r��.._�L� ��
Sign re of Contractor Date '
S� j� � :,�l� . �- �= �'�
� "'�� Sanitarian's
gnature Date issued
Sanitarian's Signature Date Completed
Sketch well location on reverse side.
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