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Receipt
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Date
�Permit requested by: . � ��1�
vner/pros ective owner/agent: YM� M'o /��„' �S
ddress: / �,� �- ���� `5 �
�Oir��«'1 �/� � �2 7 S7 3 —
ome Phone #: �eG�'�r�
usiness Phone #: ���1'--��7�-- � .� �J �"`-
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Name and addre5s of,curcent ow
���
. Property Description: Lot size:
Tax Map#: /a �' � 6 � -
Parcel#: _
Township:l�� �"���� •
. Directions to property: State Road #& Road
iames, tc. ,�� !'►�
���,�� /�Sr/l �,/ � � ,� Jor�s
Number of occupants or people to be served:
7. Dimensions or Proposed Structure:
Width: 78
Depth: ��I'�
8. What type (if any, additions, expansions, or
ceplacement is anticipated to the structure or facility .
'�hat t}�is sewage disposal system is intended to serve?
�. W ater s ly ty pe:
private public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No �
If so, identify location:
10yType of structurelfacility: Proposed: DExisting: Q
Type of dwelli :
House: obile Home: [� Business: ❑
Type of business:
Number of Employees: � . "
Number of bedrooms: _
Garbage Disposal? Yes ❑ o �
Basement? Yes � No If so, # of basement fixtures
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PerSOn COunty HP.alth Department for a site evaluation for the on-si,
sewage disposal systein 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 tliat before an Improvements Permit can �.
issued, I must present a survey plat of the property to the Heal[h Dept. I understand that in the event I have �r�t
delivered a survey plat of the property to the�Health Dept. within 60 DAYS after the date of the evaluation ot'
the site by the Health Dep[., this application shall become void and all fees paid forfeited.
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Signc� Owner or Authorized Agent
�ermit Issued ❑ Signature ' Date ' � ,
PermiC Denied ❑ . _ _ _ ^
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,�,,R � �..i`> D- $13 �,ti x a ' "T 7�� fiK4r�.x�C� 4`C.a���..kx iN„ - �� z3.,Y "' t � &;.x ,� y,Fs �: ;'�s_vK °xz �:(f's�' �.�n "a'Fs �. �a" -r "$,� < �`� x� ``"�_u:
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1. SLOPE(%1 S. 5 S ....._ S..
PS PS PS PS
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2. SOII.7FJCiURE(12-36[NJ S S- --- _ .. S.. S
(SANDY. COAMY. MYEY. NOTE 2:1 CLA17 . - PS , _ .:: .. . . PS . .. .. _
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3. SOILSI'FtUCi11RE'(12-361N.) • S-' S S -- S -
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3. SOILDF.PT}i(ITt.) S S S S
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S. RESIRICTIVEHORrLONS(iN.) S � .. S _ _... S.. _ . � ' . 5:-.
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(ERERNAL & II:TEANAL) , PS PS ps . . PS .
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7: SOII.YERMFJIBII.ITY ` S. ' S S S
(PFR�COCAATION RATq PS _ PS �' PS • PS
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II. AVAII.ABLE SPACE _.' , S -� S . S 5_
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9. SiIECLASSIFIG710N(SEEBEL011� • • : ., : . . � . ', . .
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SOtI.SERIES `:: : •• - . _ . • - _ ' . . . .
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RECOMMENDATIONSICOMMENTS: � �
SITE CLASSIFICATION DIAGRAM (Include: Soi] areas, property lines, roads, streams, gullies, wet areas, fll :
areas, weUs, water bodies, slope-pattems;'etc:) °--- -� c:tir.,►�Roaoc�PPSEcs�+�+�NCE�c ,
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PERSON COUNTY HEALTH DEPARTMENT
V,�ELL, AND SEWAGE SITE, LOCATION IMPROVEMEN'T PERMIT
Not for waste water syste�n 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 # � �o�
Zoning To��vnship (d5 v �O�'IC
Owner/Contractor �y�v� � e-f--1- %� 4►''�'� 5 Date 1 Z-�-/- 9 7
Location/Address �-..l�r-c�l � �'J't � l 15 F201 ��2- o rti � �on�S 5-b �'e- � .
�� (�y� � ' ��5-�— �tS-F- �1 /oS. _ S.R.#
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area 3,��0� Size of Tank � b0 D�-C`Q
SFD l/ Mobile Home Size or Pump Tank /V�
Business # of Bedrooms �3 Nitrification Line_ L1D0 `k�3 �
Max Depth Trenches a�/ "
Permits may be voided if site is a ed or intended use chan ed.
Well and Septic Layout by ,
,
Comments:
� ' � Q p� ,rv�� 1 p .d *- �'�'t � ��- �P�/�-l-. I�e.ai- r>.�- s
Date ,?-� 7�9Ss Installed by Qf;.,,�,,,,,�,. o�o- _ Approved by �,G`P�S� �_
ell Permit Paid 0' WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Rec�uired Slab
Public Replacement Air Vent
Site Approved__ ✓ Required Well Lo�
Well Head Approved Well Tag �/
Grouting Approved �
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This report is based in part on information provided the hc
representative in the application submitted for this permit.
neowner or his/her
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 anplication. Neither f'erson 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 O1/9S rev.l.l
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PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
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Date: �-�1=q�r '
Owner. 1=',r ,Y-� e-�
Location/Direc[ions:
SR#
Subdivision N�me: ._._ Lot #
Drilling Conrractor: —�� Cu�.� �------..
W%LL CnNSTRUCTION ��-�- �
Distance from Nearest Property I.�ne_____�p _ Distance froin Source of
I'ollution__�Qo ______ '
"I'otal Dc��th:_�[�__� Ft. Yiclr'.____�v....__ C7�'M Static W;:ter I.,evel�s"___;=;-
Water Bearing lones: Depth �cs ___j�t.___ ��Ft�Ft__��! Ft.
Casing: Dcpt}T: From �3 to_ (�� Ft. Diamctcr: � U�c}��;
TYPE: Steel � Galv�inized Ste�l �
If Stecl, does owner app:ove: Ycs No
" Weight: Thickness:_�_ Height Above Ground:� Inches
Drive Shoe: Yes �" No
Were Problems Encountered in Setting the Casing? Yes No v
If "yes" give r�ason:
Grout: Type: Neat Sand/Cement �— Coricrete
Annular Space Width Inches
Water in Annular Space: Yes No
_ .. Method: Pumped � - Pressure � � Pourzei-� .... . . , . :
- Depth: From C� :o a o Fc. . .
Materials Used: No. Bags Portland Cemen� Weight of .1 bag�_lbs.
I#' mixture (sand, gravel; cuttings) - Ratio: co
�ID Plates: Yes ✓ No � � �� �
�� 4 x 4 slab Yes � No �
I HEREBY CERTIFY THAT THE ABOVE INFORM�ITION �S CORRECT AND TH AT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSO�T C�Ui�'I'Y HEALTH DEPARTMENT.
Signaturc of Contraccor Datc
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