A40 268Amount paid
Rerseipt' ll
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ts Permit.(Established/Recorded Lot)
ImvFovements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
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,
Date
ion of Existing System (Loan Closing)
RepaidReplace existing Septic System
Permit for New Well
_ Replace Existing Well
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1, permit requested by: .
ownedprospective owner/ gent: I�a,�n L-' �P �
Address: �� �� � � ° ` -
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ome Phone #: � 6 � - 9 � � �
usiness Phone #:
7. Dimensions or Proposed Structure:
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W idth: ��.�=
�r1�.,r1.• � h � � �a� �y �,
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?
9. Watersupply t}pe: �
Name and address of current owner:
�Q � 1 �� �- private �public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes �No j�.
If so, identify location: / v 6- S � 5 J ��.. J
Description: Lot size: l l� � �
Tax Map#:
Parcel#:�_
Township:
Directions to property: State Road #& Road
ames,�tc. /' / �%��
/�.� � H-c.ti /•�i G c. � � l I � ' `" �
Number of occupants or�e to be served:
10. Type of structureJfacility: Proposed: L7Existing: Q
Type of dwelling:
House: ❑ Mobile Home: L� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �—
Garbage Disposal? Yes ❑ No �
Basement? Yes ❑ Nofl�I�so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES• �
I hereb make application to the Person County Health Department fori of th s auali� tion ahe t�eite
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sewage disposal system for the above described propercy. I agree tha[ the conten PP
and represent the maximum facilities [o be placed on the propercy• I unat before ntlmprovements Perm t can be
intended use changes, the permit shall become invalid. I understand th
issued, I must present a survey plat of the property to the Health Dept. I un afte thetdate ofhhe evalua on of t
delivered a survey plat of the property to the Health Dept. within 60 DAYS
the site by the Health Dept., this application shall become void and all fees paid forfeited.
Signc� Owner or Authorized Agent
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B 2469
h PERSON COU'NTY HEALTH DEPARTMENT
��,;. WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
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.
T� Map # A y � Parcel # 2
Zoning Township O (�
Owner/Contractor � M � p_ � Date — �—
Location/Address 1 � �15 T
Subdivision Name
Lot#
S.R.#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area � �• 1( � Size of Tank �
SFD 1� - Mobile Home Size of Pump Tank N
Business # of Bedroomsy�� Nitrification Line �� `�C� �_ _
Max Depth Trenches a � "
Permits may be voided if
Well `arid �Sentic Lavout bv
Comments:
This report is based in part on information provided the h�
representative in the application submitted for this permit.
neowner or his/her
The environmental
health specialist is not responsible for false or misleadiog 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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. - Date: '
Owner. � �aM I �
Location/Directions: _
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Subdivision Name:
Drilling Contractor:�_
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PERSON COUNTY ENVIROPIMENTAL HEALTH
WELL LOG '
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Lot #
. WELL CONSTRUCTId'N
Distance from Nearest Property Line lb Distance from Source oF
Pollution .I oo '
Tocal D.ep.th:. � Zo Ft. Yield: Up GPM Static Water Level__ Z� Ft.
Water Bearing Zones: D�epth lt°��Fi. �� F[. � F� ��
Casing: Depch: From p to�_Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel /
IF Steel, does owner approve: Y�s No
� Weight: � Thickness: /FS�r Height�Above Ground: <�i Inches
Drive Shoe: Yes ✓ No
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" give r�ason:
Grout: Type: Neat Sand/Cement ,/ Coricrete
Annular. Space Width Inches
Water in Annular Space: Yes No
_ .. Method: Pumped � - � �Pr�ssure - � Poured-,/ � �' �- . . . •, - : .
Depth: From O to �� Ft. � �
Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs.
If mixtuie (sand, gravel; cuttings) - Ratio: to
:ID Plates: Yes ✓ No � � ��' .
�- 4 x 4 slab Yes�-No �
I HEREBY CERTIFY THAT THE ABOVE INFORM�1'I'ION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON COUi�ITY HEALTH DEPARTMENT.
✓ ---
�S gnature of Contractor Datc
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