A40 273Amount paid �rj�,00
Receipt .�� ' ���6�
�
~ �-c�
�
H
�
a
w
U
�
a
-�-�4-� �
Date
<,.,.. .:�,: .m<_. . _...,. . _ _ _
Improvements Permit. (Established/Recorded Lot) ,_ Reinspection of Existing System (Loan Closing)
ImpFovements Permit (Unrecorded Lot) _ RepaidReplace existing Septic System
lmprovements Permit (Mobile Home Replace) iPermit for New Well
Improvements Permit (Addition) _ Replace Existing Well
, z $�
� � ' z $_# �" _ � 'S�Yater Sample to be: Collecterl. �
. . Y x s . s � � v . . :,.- a ;
.. ,;K� , .,..w. . ... . ..... . ... .x
... ..,> , , > ....��:, y _�'.:'.
. >... <: ... .
o. .t, ..�� . sK.. .;... a ,t...c,,.. ., , . ..,_:�, . ..;..:.. . <,.......: ...
_ Bacteria _ Chemical ._ Petroleum _ Pesticide _ Lead
1. Permit requested by: . 7. Dimensions or Proposed Structure:
owner/prospectiveowner/agent:�uP�.n�ie,�f��,1..�V Width: ��
- ��.
8. What type (if any, additions, expansions, or
�� replacement is anticipated to the structure or facility
µ that this sewage disposal system is intended to serve?
ome Phone #:
usiness Phone #: 33lv -59_ 9- 50 0 0
. Name and addreSs of:cunent owner: 9. Water su ply t}'pe:
�'- � u7-N � private �. public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No [].
If so, identify location:
�
: Lot size: I� 4.� /� �_
Tax Map#: � `� D
Parcel#: ���
Township: � �.A-� �.���e� _
Directions to property: State Road #& Road
�
Number of occupants or people to be served:
10. Type of structure/facility: Proposed: C7�xisting: Q
Type of dwelling: ,�/
House: ❑ Mobile Hame: L�1 t3usiness: ❑
Type of business:
�Number of Employees:
Number of bedrooms: ___�__._
Garbage Disposal? Yes ❑ No �
Basement? Yes ❑ No�f 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 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 pecmit 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.
W /�
� C%c�� C - �� ����i�.��v
z Signcc� Owner o Authorized Agent
Permit Issued ❑ Signature Date • .
�•
Permit Denied ❑ -.
Plat Observed ❑
L . : z . FACI'ORSSTTE EVALUA'#702i ;: < . ':; �`ARF�S �. ; ,. , A1tFJt 2 f A� 3 ,� ;' y A1tFa d , .
r ,. . .. , . : ... ,, >::. .. :..
. �.
�. �b. .. .... .... . 2 ....... ....:... F ...
, :s . .:s."�:>�
. . . . .. :. . ..
1. SLAPE (%) S S S S
PS PS PS PS
U U U � U
2 SOIL7'IX7VREl12•36INJ S S S S
(SANDY, LOAMY. CLAYEY. NOTE 2:1 CLAY) PS PS PS ' PS
U U U U
3. SO1L STRUCilIRE (12•)61N.) 5 S S S
(MYEY SOILS) PS PS PS PS
U U U U,
S S S S
3. SOiLDEP7i{ (IN.) ps PS PS PS
U U U U
3. RESTRICI7VEHORtZONS((N.) S S S S-
(II.IPERVIOUS STRATA. ROCK) PS PS PS ps
U U U U
6. SOILDRAINAGFJGROUNDWATER S S S S
(FXTERNA(, S Q�ITERNAL) PS PS PS PS
U U U U
�. sone�x�Ena�urY s s s s
(PERCOIAAT70N RA7� PS PS PS PS
U U U U
E. AVAILAHLESPACE S S S S.
PS PS PS PS
u u v u
9. STIE CLASSiF'ICA710N(SEE BELO�try
SOlL SERIES
S•SUITADLE PSPROVISIONALLY SUTIA6lE U-UNSUTtABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.� C:�AM(PRO�DOCSAPPSEC.Sr1 FWANCE.PC
Date: (�'/Co �d '
Owner. �_�.��
� io /D �ctions:
Subdivision �N1rne:
Drilling Contractor:.
.. . _
_ PERSON COUNTY ENVIROIIME2ITAL HEALTH '
�
WELL LOG
Lot #
� i/ i ri
WELL CONSTRUC'I'ION d
Distance from Nearest Properry Line LC� Distance from Source of
Pollution ! Bv '
Total Depth: /aU Ft. Yield: o�CJ GPM Static Water Level a S� Ft.
ti'�ater $earing Zones: Depth s Ft._7 � F� 8� Ft� /oa �t,
Casing: Dept}i: From G to �3 Ft. Diarneter: �`�Y Inches
TYPE: Steel � Galvanized S[eel �
If Steel, does owner app:ove: Yes No
� Weighc: � Thickness: .�is' Height�Above Ground: l�l Inches
Drive Shoe: Yes / No
Were Problems Encountered in Setting the Casing? Yes No �
If "ycs" give reason:
Grout: Type: Neat Sand/Cement �- Concrete
Annular. Space Width Inches
Water in Annular Space: Yes No
_ .. Method: Pumped � - Pr:ssure � � Poured i ��- -. � � �. : .
Depth: From c5 to �b Ft. . .
Materials Used: No. Bags Portland Cement Weight of .1 bag__lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
�ID Plates: Xes � No � " �� �
�� 4 x 4 slab Yes � No
u
I HEREBY CERTIFY THAT THE ABOVE INFORM�ITION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C�Li�'I'Y HEALTH DEPARTMENT.
. �-�
ignaturc of Con�ractor Da�c
S80•10'09"E
448.�0�
�7C
.14 AC .
N83•38'07'�E
. g03�35
107AL
:�,
�; 17 B
.14 A��
��_�c�` .
.. � � —__._..
��
��
sl � � I�g
,
. �,
;
. �,`` �o � � N� t ; :_ -, -
' . �—___ —,
-- - .
. IF ' �\
S80•70'Og��E �S
. 75.47� ' . S-00-a3-4t-E 10.00'
� �s ----. _
�-- S-00-03-4' -E 10.00'
�S �
83.60' IS
�- -- ,-00-03-�t-E 44 48'
. 90 6� I
,
IS ` '
; ;5 �
� UCII � .
�5 .� �
t�o ' o� � �
� � i, �
�a
. � ,� �
`.�,�. iF'
.� ' CONTROL �
' CORNER � �
� .
THEOoOBE'�OLLIP S446RKER
�
�
�
�
a
w
�
a
B 2298
PERSON COUNTY 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 6een issued.
Tax Map #��(� Parcel # p�� 3
Zoning Township � \ p`�- (� : � @,�
Owner/Contractor � V, � e�; e._ `'�Q I( 2.�i Date�_��} — �j �
Location/Address �-(�,, �Q1�- M',��s CZc� �L C�l �nct..t �:,� �_�-�+e_s
`� . L��- o�-E� E n�!-c, l�,-I-� s.x.#
SubdivisionName �jpr�;cZ� E'��cx�4eS Lot# 1`�j�4
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area I• �I 2�"C Size of Tank � bbC�
SFD �/ - Mobile Home t� Size of Pump Tank
Business # of Bedrooms�_ Nitrification Line �S 35 ' X 3�
Max Depth Trenches oZ 0`'
Permits may be voided if site is
Well and Septi�Layout by
0
Date (� -- q- qg"Installed by.
or intended use
�-� v.�C� ( � '- (� l/ �
Approved by �t/.,r�P.�� �-.�� _
Well Permit Paid WELL SYSTEM SPECIFICATIONS
Individual��Semi-Public Required Slab
Public Replacement Air Vent
Site Approved Required Well Lo�
Well Head Approved Well Tag ��
Grouting Approved,
Comments:
Date
Installed by /� ���.U�- Approved by
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 cor►ditions 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 environme�tal 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