A40 242, Juu��3-95 02:�16P PERSON COUNTY HEALTH O � ` P.02
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tt�pravements Perrnit (Establishcd/Recarded Lot)
Ittipravements Permit {Unreccyrded Lot)
Irnpr�vements Pertnit (Mobile Home Replace)
Improvements Permit (Addition)
____ Bactcria
_ Chctnical
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_ Reinspcction c�f �xisting System (Loan Closin
„_ Repair/Replace existing Segtic System
_ Pertnit f�r New Well
_ Re�lace Existing Well
Water Saimple to be C
�_ Petroleum
l. F'ertt�it reyuested by: '
�wner/prospective awner/a cnt: � `l A�.1 �r�,
Address: 231 (�U-���('J
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otne Phone #: °C l � - � �=�I 1 �i-5�j
usiness �'tioric #:
. Name and addtess of currcnt owner:
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. Property Uescription: Lot size: �T_3DA I,bS
. Tax Map#: � �f 0
Parcel#: "�-� Z
Township: � 1�
. Directions ta prc�Perty; Statc Roacl #� l�oad
f �tmes, etc.
._ Pesticide _ Lead
7. Dimensi�ns or Pcoposed Structure:
Width: 70
tla.,rl.. 1 ► f
8. What type (if any, adclitions, expansions, or
replacement is anticipated to the sttlicture �r facility
that this sewagc disposai system is intended to serve'?
9. Water supply t5•pc:
private � p�.�blic � comntunity ❑ tiPring L
Are any wells on adj�ining pruperty'?Yes LrN� Cl
[f so, identify Icxation:
IQ. Type of stnieture/Facility: Propc7sed: L+�xisting: CI
Type af dwelling:
%�ouse: Cl Mobile H�me: C�Business: ❑
Type of business: _
Nutnber of Employees: 'f��N�
Nut��ber c�f bedrooms: ` 3
Gar�age Disposal? Yes Cl No C�
Basemcnt? �'es ❑ Na G�'tf sv, # of Eiasement fixtures:
� G. Nutnber of occupanes or peopic to be served: .,�_
CLEA�tLY S'�'AKE ALL CQRN�RS QF T�E PXi()PF,RTY AND TN� COKNFRS ON ALL
PRnPQSEll STRUCI"URES.
1 hereby rnake application lv the �'ersOn Couttty Health bepaxtmetlt for a�ite evalu�ticm for the �n-sitc
sewage disposal sy5tem for thc �bove. descrit�cd prc�Perty. I agree that the contents of this a�Plicaticm are tr«e
and cepresent the tn�ximum facilitics tc� he placed on the �raperty, I unc�crstand if the site is altcrcd c�r the
intended us� changcs, the pemiit shal! hecome invalicl, a undcrstand that Licft�re an I►ttprovements Permit can be
irsued, I tt�us� present a survey plat of the property to the �-Iealth Uept. I undcrrtand that in the event 1 havc not
deliverecl � survey pl�tt of the prop�rty to the Hcalth DePt. within 6Q X)AYS ufter thc d�tte �F thc ev�luation of
the site by th� Health Dcpt., lhis applicalic�n shall bccume v�id and all fees paid forfeitccl.
s�g�,��
� or Authai•ized Agent
1 ' �
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT PERMIT
Tax Map # �} �p Parcel # �-�.
Zoning Toyvnship ��Y' °
Owner/Contractor
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Date 6-26�
A 0!+40
Layout As Installed
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SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area j, b���-� Size of Tank JB-�3�
SFD 1/' Mobile Home ti Size of Pump Tank
Business # of Bedrooms�_ Nitrification Line �a O�,�'3
Max Depth Trenches
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or intended use changed.
Well and Septic Layout by l�J.,G��% �
Comments:
Date �+_zr �,� Installed by ,�/L�-��c/CrS�-1r Approved by
blic
WELL SYSTEM SPECIFICATIONS
Semi-Public Required Slab V
Replacement Air Vent
te Approved �' Required Well Lo�
ell Head Approved Well Tag
�outing Approved
Comments:
Date
Installed by f?g,�,P,� /�,I�ccia��.,�9rpproved by.
Tivs repor{ is based in part on information provided the homeowner or his/her representative in the application submitted for this pemut 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 concealed conditions on the property or for statements in this repoR that may have resulted from false or misleading
statements provided to him in the application. Neither Person County nor the environmentat health specialist wazrants that the septic tank system will
continue to function satisfadorily in the future or that the water supply will remain potable. c:�amipro�petmitsam Ol/95 rev.1.0
ORIGINAL
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I'1•:ll:iUl`I I.UUIJ'1'1' 1'�IVV I llul�l'll•�11'1 A1� III.A1.'I'll
WELL LGG
Date: � � -� —Q6 ' . . SR#
Owner: �� �� � �i� T<—(Z
Location/Jirections: , �
Subdivision Namc: .
I�]
p�l —Lot #� 3e -
Dnlling Contractor. WEL� CONSTRUCTION
Distance from Ncarest Property Linc
Distance from Source of
Pollution
t.
Total Dep.th: Ft. Yield:= GPM Static Water Leve
Ft. Ft. F� Ft.
Water Bearing Zones: Depth / Inches
Depth: From � to � Ft. Diamet✓
Casing' . Galvanized Sceel
TYPE: Steel No
If Steel, does owner approve: Yes _
Weight: _ Thickness:�— Height Above Ground: _ Inches
I?rive Shoe: Yes _ No �
Were Problems Encountered in Setting the Casing? Yes _ No
I: "ycs" givc;c:�son: Sand/Cement Concrete
Grout: Type: Neat �ches
Annular Space Width 12' No
Water in Annu�� Space: Yes
Method: Pumpcd� -- Pressure Poured ✓
Depth: From_ to � Ft'
Materials Used: No. Bags Porcland Cement Weight of .1 bag.______lbs.
ravel, cuttin�s) - Ratio: ��
If mixture (sand, g d . .
ID Plates: Ycs ✓ No
.t Y d �lat, v�c�-No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CO EGU ATIONS S T
THIS WELL W A S C O N S T R U C T E D Y N A LTH DEPARTMENT R
FORTH BY•THE PERSON COUNTY HEA ..
. , .
• , ��=�=q(�-
'� Signature of Contrac .%.-• llatc