A40 261P� �-�°°��,���-3
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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
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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,
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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
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� 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:�
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Date Installed by� �� �Otihn Approved by
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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