A40 272ount paio j!�'1�D0
�ceipt' fl � l3'79
, � � �,_ ioa2�
�
H
O
�
�
W
U
�
a
Improvements Permit.(Established/Recorded L,ot) �_ Reins
_. Repair/Replace existing Septic System
� '¢'—q ..
Date
on of Existing System (L,oan Closing)
Imvrovements Permit (Unrecorded Lot)
Improvemencs Permit (Mobile Home Replace)
rmit for New Well
Improvements Permit (Addition) I Replace Existing Well �
1. Permit requested by:
owner/prospective own'
Ad�ress: _ . l� `� 1 _.
�
z
ome Phone #:_
usiness Phone
t: �
1 ��
� 3�g
7. Dimensions or Proposed Structure:
Width: 36 � 40 16 Qa �'�" �
Depth:
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?
I�Iame and address of current owner: 9. Water upply type: '
� C' private�. public ❑ community ❑ spring ❑
y ,�m�v �,, .t�+J t
7— Are any wells on adjoining property?Yes� No Q.
If so, identify location:
Description: Lot size: l• S �¢cres
, Tax Map#: � `r"
Parcel#: `
Townshin• l�c�� e� .. � i S (=��-�`��'�►Y-r
. Directions to property: State Road #& Road
ames,�tc.
0 1 ��o�
c � � , l =�
T af,a o-� � � (� o�•_
. Number of occupants or peo�
�o�
to be served:
10. Type of structurelfacility: Proposed: ClExistirig: Q
Type of dwelling:
House:�Mobile Home: L7 Business: ❑
Type of business: �
Number of Employees: � . : ::.
Number of bedrooms: 3 �
Garbage Disposal? Yes ❑ No � .--
Basemen[? Yes ❑ Nofl 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 PeICSOn .COuniy_ Health Department for a site evaluation for the:on-sit�
sewage disposal system for the above described property. I agree tha[ the con[ents 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 tfiat before an Improvements Peiinit can 1
issued, I must present a survey plat of the propeccy to the Health Dept. I understand that in the event I have nc�
delivered a survey plat of the prope�ty to.the:Health,Dept. withi 60. DAYS after the date of the evaluation of
the site by the Health Dep[., this application shall�become void nd all:fees paid forfeited.
ignc Owner or Authorized Agent
� t Si nature � � � .C�!�r� Date 3�' ' ' � � - �
�errrii[ Issued �.J g , ,
Permit Denied ❑ . ' ' '
. . . ..,. .... .
- -
Plat Observed '-•
. . . --- • -� • . - .. . . . . - . - ... _ . . :j ..
. . _ . . . . . � � t;
_ : . . • ����t�� .--. . :.... � , . -. -- . ,..
. ����� . ..
' .. .. • . . . . � • ' ' .'. ....Y
• � . . .... .�r... .��.. � . .. . . . . . ... _ ... , �
� . �� �
_- . � . .._ _. ._:�:� .��. .. � .._ .. ... .. .__ � . � . . ._,: . -� - :
. . . . b :_ ._._
. . �- . . . . . ���-� . _ . . __-;..�� ^.
� _ �� �_' . .
_ �. �� �� . .
_ _ . ._ .._ .. . . ---- � � `�� �.� J�-��z%-:�-� .. .-,--�... > � = .. ...
�_.��..._ .. .... .. __ . ..;.� .
...._.. ... . . .
. . ....
:�`.s�%°�'Ts"���`��C"�:�..�,tu'�SiiEkvi�.ti�_.�.s�:'���'.�'�'���. �''� Y+�£•. ...: :.� ��� � .,.�..w . � -: . . .�..�...i��sz �,,�.t:_'� � 4.'�e�. .
I.SIAPEfA) S S S -.._.. S.... _ �
►S pS . . .. .
� V . U, .
..
L SOD.TE7Ci1JRE .) ' � • � .. .. ..,,,'.. ...
S
(SAT7DY. LOAMY.�. N07E 2:1 CLAl7 ..• .__. . .... .. .
S . . t3- _ � PS:T1Yrr+;;'-- f -
� _... ...' ... . . ' . V .. � ..�.. ,,,;�sni U�s:a�s.wvs:.w+.c.:>.ii�.
x SObSiRUCIVRE(12•361N.) ' . L _ �� S • _ S . . . • s — . '.: i $'.�;�:7;'f•..� � " ._ � ,,•• :
(MYEY SOf[.S) S� � /� . PS PS - '' `F; � ` ` . .
. U U V • U ' -:':
, SOII.DEP22i (U:J ' � // .' ' • S S S . . .. -
3 n � . . .
v U U
S. RES7R1C71VEHORiLONS(TN.) /!( S ' ' � _ _.-. S• .�. _ . . . ... . ?::._. _ :_ ....
(SMPERYIOVSSiRATI�ROCIq_.... . 3(�j � .. .... K „ PS .
. . � . . . . . '_ . .. � U- . . •. �r U: - v � •�.-�..- .a
s. sonnsuiru�cRoin+nwn�x ' . . _ . ... .. . .._. . S .. . . . :. . s , , s.� ,_,._.. . , -- ..
ctxtFRrcu. tt u;rrFxx '�. : � • ri � . . . • .: � - :: ., : ,"~.. - : .
�t�� �( � : V '' . U • -. U . `r. U .' g
7: SOII.PERMEABII3TY ' ' ., '. S S S
_ cr�cot.o�nor{w��a : . � � - . .: . es r.s. �
' �: �`:•i1-:� . � . � . _ _. .. :,t • v: - � u _ : � u.., � : �: u.. . .
� t� nv�uastEsrncs . . : . -. • s . • S . . S -- � • S : � , : ._ � . � .
��'I/� ' , , rs • PS>�t ,c, .:_•.••.;
tit.: ;i��o.' . _ : ., '.• � p p . p. U-, s! k•
• 9.iS(I5�.7.71$STF]GT10N(SEEB0.0� . . . , .. , . .. ', • . . . . ..`':`• "�'-?:'•'':i'� "4�:i;:t:�,.
� _.o,.. � . . , . . . ... . . . .. . . •S.irh-,:
SOiLSERIES.`�:: . . . . . ..,,r .. . , . • .. . -• . . ' 'L,'jtM,:;:i�:i..
. • . .. . � SSUITAHts `KTROVLTIONAI2.YS1JfTADLL lL1JHSVfIAIILZ'•.: .;.y .: '•.�-:•i:•'ISr•d•. � .
RECOMMENDATIONS/CONiN1ENTS: - ` �``� . _ . .' . • . . ,� , , '~� .
�t�•1:: �•cit�,�ttt �i
. ;
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas;._fi11 ;:�
. }:
areas, wells, water bodies; slope pattems�'etc,� '"' C.'NMWRGDOCSVIPPSECS�� �AN�� •�•`
�\
���
�
a
W
U
�
a
b
�
_ . . 6 .2133
� ' PERSON COUN'�'Y H�ALTH 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.
Tax Map # �' �-� Parcel # �. ��
Zoning Township JC-�� �-..
(l.a��r�t"►'nntrartnr a�.� �, �,, � Date � — �% -'� �
�ation/Address
� � - -
Subdivision Name
Lot#
S.R.#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area � 5 Size of Tank �8�+-�-
SFD ►/' Mobile Home Size of Pump Tank
Business # of Bedrooms 3 Nitrification Line �O' X 3�
Max Depth Trenches 1$'�� �'
Permits may be voided if site is altered or intended use changed.
Well and Septic Layout by /,�%.•r� ����-
Comments: , s�,� Qd-�. �l,���-dZ-� _�
Date $-Zl -�8 Installed by %w�,�;� L'o��'e Approved by
�
Well Permit Paid WELL SYSTEM SPECIFICATIONS
Individual 1/
Public
Site Approved �
Well Head Approved
Grouting Approved ;
Comments:
Semi-Public Required Slab � 'u �
Replacement Air Vent �/ � _
Required Well La� i/ S 1�9� 1�
5�13��1� �J Well Tag ✓ ��.�q�Y,�.�i
Date � Q� Installed by�jlQ,� �?.�Q,�l � Approved by
.1i,�u�v„r�
This report is based in part on information provided the homeowner or nis/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 healtn specialist is also not
responsible for concealed conditions on the property or for statements in tnis
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 01/95 rev.l.l
/ � �
,
, ,
/��•�:�; =�" �! !
�a.:�. �� `' ;o� ,
� �Y: . '�%. •r• . �8Z
�• -� � �:
l t�;;� :*.' ,[
'�r; ,� . /�
/ , . • �\
/ �
' � /
/ � i
-� �
/' r�^ /
v/
�,� ,��
, � �
I � N /
/ � o 0
O
Q � �v /
, �� �
�
� /
r
; I
,
� ��
,
,
.:. i . �
. �
.Y ,
�, /
SN;' I
,... ��sS.�
_ # �
�
�' ' j SI
{ /
/ ' �
i �
/ Q� �_'` �
,'K�.:� , \ ` �
♦ i1 I O �� �
{
t,I. � � �
\
�bMo�S% �z• o�N
` � 9ZT
/ �
i y,� Q� ^�
��� z � �� � 9zr
S� 8Z' °�S �
�
��
ca
�
05� •d 'azz •e•o
3�I21 110�S SI121��
�� � /
i �' ��
u � �
� a j
ry � � �.
- t ,-
���
��` r�';,' _ ��— \ • . . . . . . . C T
ySfirN:: • `.` � i:'.''. . �;::�; �i: . • . .. ..
Z09�'d
L6 "d
SNINMV
Date: s� �q� '
Owner.
Location/Directions:
Subdivision NZrrie:
Drilling Contractor: _
_ . _ ; �� ..
_PERSON COUNTY ENVIRONMEIITAL HEALTH � ' • � �`�`�'����� .
� WELL LOG . _ ' :`A'�r,,t� �;
, . � .
_ SR#
Lot # --
WELL CONSTRUCTION� �—
Discance from Nearest Properry Line ��J Distance from Source of
Pollution_ /Go `
Total Dep.ch:_ !�D Ft. Yield: av____ GPM Static Water Level aS _Ft.
Water Bearing Zones: Depth SSS rt. 7a Ft 7F Ft� 90 �t. /�J ,�r-
Casing: Depth: From�_to Y�_Ft. Diameter:_�_ Inches
TYPE: Steel - Galvanized Steel �
If Steel, does owner approve: Yes No
� Weigh[: � Thickness: !b� b- Height�Above Ground: ��( Inches
Drive Shoe: Yes v No
Were Problems Encountered in Setting the Casing? Yes No ✓
If "yes" give r�ason:
Grout: Type: Neat Sand/Cement /� Concrete
Annular. Space Width Inches
Water in Annular Space: Yes No
_ .. Method: Pumped . . Pressure � � Poured � .._ . . - •, - : .
Depth: From_ O :o 02 a Ft. . .
Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
�ID Plates: Yes � No � � �� �
�� 4 x 4 slab Yes ./ No
IJ
I HEREBY CER'TIFY THAT THE ABOVE INFbRMr�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH �3Y�THE PERSON C�Li�ITY HEAL,TH DEPARTMENT.
� �-G •�i--
ignaturc of Contractor Dat�
�..