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A40 261P� �-�°°��,���-3 e� G ��� , � APPLICATION FOR SERVICES ts Permit.(Established/Recorded Lot) ImpFovements Permit (Unrecorded Lot) provements Permit (Mobile Home Replace) Improvements Permit (Addition) _ Bacteria 1. Permit requested by: . owner/nrosoective ownet _ Chemical � a v Home Phone #: G - � � usiness Phone #: ��ci _ a ,�-��-�6 Reinspection of Existing System (Loan Closing) Repair/Replace existing Septic System _. Permit for New Well _ Replace Existing Well _ Petroleum � _ Pesticide � _ Lead 7. Dimensions or Proposed Structure: Width: ag Moci�ula��- �1o�tne 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? Cl bof�P � . Name and addr��s of_current owner: 9. Water supply type: C�,M `,, � '(1 ,,�� �� , t ,. �( o�(`� _ private �public ❑ community ❑ spring ❑ `- Are any wells on adjoining property?Yes ❑ No �_ If so, identify location: Description: Lot size: 1 • Tax Map#: � Parcel#: �-� Township: � . Directions to property: State Road #& Road Number of occupants or people to be served: 10. Type of structure/facility: Proposed.'�Existing: Q Type of dwelling: House: ❑ Mobile Home: Business: ❑ Type of business: Number of Employees: Number of bedrooms: � Garbage Disposal? Yes ❑ No � Basement? Yes ❑ No� If so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPER�Y AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the Pet'SOn 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. Si Authorized Agent Permit Issued ❑ Signature Permit Denied ❑ Plat Observed ❑ Date : FAcrOxs-st�Ev.a►.vAnor� ;A�'t i�x2 r n�3<; i�+a ,_,.. _ . 1. SLOPE (%) S S S S PS PS PS PS U U U U 2 SOIL T'IXNRE (12-36 IN.) S S S S (SANDY, LOAMY. CLAYEY. N07E 2:1 CLAY) PS PS PS PS U V U U 3. SOIL STRUCIURE (12•361N.) S S S S (CLAYEY SOILS) PS PS PS PS U U U U 3. SOIL DEPTFi (IN.) S S S S PS PS PS PS U U U U S. RFSIRICfIVEHORIZONS(IIJ.) S S S - S (IMPERVIOUS STRATA. ROCK) PS PS PS PS U U U U 6. SOTLDRAINAG&GROUNDWATER 5 S S S (EX7ERNAL & IMERNAL) PS PS PS PS U U U U 7. SOILPERMEAB1LifY S S S S (PERCOLOATION RA7E) PS PS PS PS U U U U 8. AVAILAB(.E SPACE S S S S PS PS PS PS U U U U 9. S17ECLASSIFICAT70N(SEEBELOW) SOIL SERIfS S-SUITAIILE PS-PROVISIONALLYSUITABLE U-UNSUITABLE RECOMMENDATIONS/COMMENTS: SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope patterns, etC.� C:VIMIPR0IDOCSAPPSEC.SM flNANCE.PC ''Y," 1 N. .iJ�" \ /N�{T � '. C I . . f:' I . . . .. �' ' '.�T i7 (A �}, { , ��j'".� "�`�.� ���4� 1./r J � �, r .(j1 't� 4 �. A ' . ' �� ! Q)�.. .;� K � ; F:(•k.:.� y .r,� ,�l•r. ! .. � r�s ?X` r�' r .: + s . ,Y� • � .rd�x1°� '�'p�'w�.� ,. ,„ � �. �i s � � • . 4� � C �x����r�� -�Y r,a f�� � 4 m[O :yy�� ,�"*' : �' ;t:" S c ' ,;� � p� t!1 � .. � O O ` �( i i �! �r i � � .f , : � . ` .. . . . � .. 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Q �a".�{ � 4 � r � eJn'��`� "f f� '?+'.� y��: r �i ♦ l - � ....• , Y.� ,. . � .� , . �7�.��� iFAFT � n.� •�,����.��.f.,J.�f:.�`t y��.�Y-C I�,�i'�+�"J'� r-A�F'( a 4 �3 a y.. r 4�l"}�. ��".. �'� .ry . t e. t� � dr;,�"� ��tkr i �� 1'� X1R �+y�;i(w"A xfi4'it�ji�j P,y�7�CS.���fi.,�ni J -i Lh! � r.�.'� .�'�. �, • ``�'ly;, .� �. . r �,._. , . . . - . ^.�' �,, -h i �'`y r" f�'(f 4.}C'I`�l� .,vu� .���.r� � 1k-.�'� � M .i � 'C,�1�, a t�-Y � .. ��'� ,;f'� ; . . ` i r . rJ:i�l�.�_::�;%.i.{.'1`Ifitk , `� ,�:�r.t. :°37���}�L�"E. . . �!'�',�'.i.J;,.. ..� ,��••Se�. �t.:��" . .JL.� ,. �:�^� f1.�..�� ,- "i. . .. . . . . c 1.� Z � a W � a PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT PERNIIT Not for waste water system construction. No permit(s) for Construction Location or Relocation Activity shall be issued until Authorization for waste water system construction has been issued. Tax Map #� � Parcel # �� J Zoning Township �=L�47!?lV�2 Owner/Contractor ,�,s,� � •; ,M � � yL,c_ R Date ,s�- 3! - 9!a Location/Address �/r„iy �,s -� ` s t,� o� Nu�F .Po� /� A�i2�X . / ,�-ric�:� �i�G l�F� S.R.# // 'Y / Subdivision Name Lot# SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area /. o f3 AG Size of Tank c'x � s'r�N r� SFD Mobile Home t/� Size of Pump Tank �I/,� Business # of Bedrooms� Nitrification Line Lx is ri,� cr Max Depth Trenches Permits may be voided if site i Well and Septic Layout by� Comments: �!, �, „ ,��„ �c S YS or intended u�e c�ged. Dates'-3/-9�- Installed by �x iS Ti�lCr- Approved by Well Permit Paid ❑ WELL SYSTEM SPECIFICATIONS Individual Semi-Public Required Slab Public Replacement Air Vent Site Approved Required Well Log Well Head Approved Well Tag Grouting Approved Comments: �/$ �,�.� �,- �� e� v,c/ N��� 4.�.rs���zl.c./�- t.� T Date Installed by Approved by, �A. L Gt? / c.����� This report 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 application. 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\permit.sam O1/95 rev.l.l � � a� U 4. c� a � A 1514 � Q e�� PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Tax Map # �y0 Parcel #�( I Zoning Township F�a� R i ucr Owner/Contractor M�� 7 m T�-u �er Date J O i 8- 9 q Location/Address_�{y,,�r /�S �� � o� �1.� FF Road. �4�v�ox � rr,a t�� / �n , lc o�� �`'-- •-- S R # Subdivision Name Lot# SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area Size of Tank SFD Mobile Home Size of Pump Tank Business # of Bedrooms__ itrification Line � � � x Depth Trenches Permit Void after 60 month r it if not �n compliance with zoning regulations. Permits may be voided if sit � tered or intended use changed. Well and Septic Layout by Comments: Date Installed by. Approved by WELL SYSTEM SPECIFICATIONS 3ividual / Semi-Public Required Slab iblic Replacement Air Vent te Approved ! Required Well Lo� _,�2� �( � 03�Cd ell Head Approved Well Tag � -outing Approved �^� � [57) _ Comments:� r , . . �e ('I L�0' Date Installed by� �� �Otihn Approved by � This repoR is based in part on information provided the homeowner or his/her representative in the application submitted for this pernut. 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 repoR that may have resulted from false or misleading statements provided to him in the application. Neither Person County nor the environmental health specialist wazrants that the septic tanlc system will continue to fundion satisfactorily in the future or that the water supply will remain potable. c�amipro�permitsam 01/95 rev,1.0 OfiIGINAL