A40 275� Amount paid �`�� `�v �
I Receipt .�� ' t(
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Improvements Permit.(EstablishedlRecorded Lot) �_ Reinspection of Existing System (Loan Closing)
Impxovements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
Repair/Replace existing Septic System
,_ Permit for New Well
_ Replace Existing Well
__..__ . ___ _
_ Bacteria _ Chemical Petroleum _ Pesticide _ Lead
l. Permit requested by: . �SaYrJv a^^ d
�wner/prospective owner/agent: � nAe�� %I ar re r
Address: 1aa�i w�cCS�c� Yr� 11 �a_
'CZ:�,r 1„ e��.n _-v1 c � rl s`13
ome Phone #: � '
usiness Phone #: � g`1 �- . a �`1 �
. Name and addre�s'o�cnrr�tif owrn
�Aw,vr. ��:� O.W I�i ✓�S
��- S l� ci� rr; ; � 1�'
��1,�vL,�,Y�. �n �, a�S� 3
7. Dimensions or Proposed Structure:
Width: `� �
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?
-1i-� a�x. -
• 9. Water supply t5•pe:
private �public ❑ community ❑ spring ❑
j� �. Are any wells on adjoining property?Yes ❑ No j�-
If so, identify location:
tion: Lot size: a ac�'
Tax Map#: �"N� � ��
Parcel#: �y ��`�
Township: � � a � . _ �� v�n
Directions to property: State Road #& Road
S (� -� �-e r �� 0.ss i��t
k�-e, a"r Y' o a� ��
k 'C-Z:v-e.� C,1,. , 1Z � . .F.�
ss Y� �
Number of occupants or people to e served: �.
10. Type of structure/facility: Proposed: C�xisting: Q
Type of dwelling:
House: Ca'Mobile Home: C� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: 3
Garbage Disposal? Yes ❑ No G�
IBasement? Yes❑ Noi3�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 PeI'SOn COunty �Iealth Depai'tment 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.
St ncc� Owner or Authorized Agent
„ �
Permit Issued ❑
Permit Denied ❑
Plat Observed ❑
Signature
Date
� � > FacroRs-s��v�.vnnox> ” � . . :��a�at �.n�x �,.'s.. ?+x�?!s ,v�+a
ae �. ..r . . ..::. . . ..: .r ... ..:
... , . � > ....; .>, . . >. . .
.�...<.« ......r..-. . . . . ._ - '
1. SIAPE (%1 PS � ps PS
� p p U
2. SOIL TEXTlIRE (12-36 IN.1 5 S S PS
(SANDY, LOAMY. CLAYEY. NO7E 2:1 CL1Y) PS PS �
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3. SOILSTTtUCTVRE(12•361N.) S S S S
(CLAYEY SOTLS7 V U U U.
4. SOILDEP7}i(INJ PS ps pg PS
U U � U
S. RESiRICI1VE HORIZONS (TN.) S S S S
(iMPERV(OUS STRATA, ROCK) PS PS PS PS
U U v U
6. SOILDRAINAGFlGROUNDWATER S S S S
(DCCQLNAL R iNiERNALI PS PS PS PS
U V � �
7. SOI[. PERMEABILTiY S S S S
(PFRCOLAA'[70N RATE7 U U � U
E. AVAfI.ABLESPACE S S S S
PS PS � ps
U U U U
9. SfIECLASSfF1CAT10N(SEEBELOW)
SOIL SERIES
5•SNTADLE PSPROVISIONALLYSUITAIILE U-UNSUITABIE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, �ill
areas, wells, water bodies, slope patterns, etc.) C:\AMfPR01DOCS�APPSEC.STIFWANCE.PC
�
B 2673
� PERSON COUNTY HEALTH DEPARTMENT
� WELL AND SEWAGE SITE, LOCATION Il�IPROVEMENT PERNIIT
'�To� 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.
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Taac Map # � y� Parcel # 2��
Zoning Township �� � : �1 e�(
Owner/Contractor � l e_ Date — 2— 9
Location/Address Sb IS�I� l�- `�; �P_c" C.�.t,�.rC�, �d %-� OR
Subdivision Name
Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area a•C��G Size of Tank�j �,
SFD y� Mobile Home Size of Pump Tank
Business # of Bedrooms 3 Nitrification Line
Max Depth Trenches
�S�-� �lo '�v�.
Permits may be voided if site is alter or intended u changed.
Well and Septic L ut by
Comments: � �r?�Ul .
S.R.#
Date Installed by � `� Approved b}f-- '
�02� ,� � 3Q-�1 Gl
ermit Paid WE L SYSTEM SPECIFICATIONS
Individual � / Semi-Public Required Slab �/
Public � Replacement Air Vent
Site Approved Required Well Log � St� H�-a I-`� �__
Well Head Approved �/ Well Tag ✓
Grouting Approved ✓�� �} (� -� I-q `� }ip�� (3;b �/
Comments:
Date
Installed by E�rrb W e,Ql C� • 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 informa�ion
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 ta�k 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
� SAMMY B. HAWKINS
DB 178 P �10
N05'19'37"E
N 344.48' TO L
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Owner: .. �..�.5� /� (,J� r��,� ---- SR#�.
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Loca[ion > ' — ._ .- __._---..
/�✓liC,C�lOI1S. ---��<i� �. Ve..r �%7.w_r.si.�......_(�c� .
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. . �fl,L? rt.-.�.... .j�t/a._/�._..__�_r�,[_.�.�.t?_ �i � �K �-
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Distancc from Neru-cst 1'ro�3cr�y ]�iu��....1� _. ./u.s llist;incc �ro�n Source
Po]lution . a �;, �,s � o,f '
To[a1,�Dep.th:� �t. �'icid: _�-Q--_.. .__ ���'M ,Stalic Wace .
Water ��earzng rLones: De �ll. �� �:� . r Level FG:
Casing: Dept�i: F P_.._�f._._.__..._ ...7-�_.._l��t. Ft.__�t. .
roin _.�_�c>. S l�t.
TXPE: Steel . --.. �---�-.__ Di�imcter: � � Inehes
� _ Galv;inizc:cl Stccl`� : � .
X.f Steel, does owncr approv�;: ��'�;: No ''�
. Weig��t:�_ Thickncs�� I-�ci . . . .
llrive Shoc: Ycs J��-��' _�ht�A�ovc Grounci:�'lnche,s'.: �.
No ..
Were Problems Elicountcrccl ir� Se:teiat2; �tie C�isin��'1 Xes �-- '
TC "ycs" bive rcasoii: --.—. No z._ �.�' ..
Grout: .Type: Neat ___----___ ;..._ _. ---- �i';
.S:uicJ/Ccmcn� f � .. . . �
Annular: Spacc Wz��l 3 ._ ��.Coricre[e . _;-;;u,,
. r'r�. .;%;
�l 1C11CS ' •�•,
Watcr in Anni�lar Spac�: �'�:;; . _._..__ �� � • . ..
Me[�1od:' Pwn�x:c�,�_._.. . 1'rc�.;::ur�: 1'c,��rccl • .r;
I�cpt�i: 1=rom__` c�------ -- -�� � '� � .._..___. I �[—. __.= . : . . ,
Materials Uscd: Nv. Z3,��;s ,l'or�.l�rrid Cc�ncn[ .. ..`:`a
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Zf mi;;tuic santl, � • . .--_. _�--- 'ght of.l�lia�'�lbs:�
�D ( ravc;l; cuct�n;�ti) - Rat,o: � ,�: ,
P�:ites: �'eS ✓ •, _-�_ �o i •��;�;.�.,�
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` Xes ✓ � No - . , .
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1'i�rmation i�e�
Z HEREBX CERTZFX TH.�T TI-IE .A,I3(�VL �NI=U�ZM11'1'�ON ZS COR
T�S WELL WAS CONS"1'IZUC"I'L1) .[(�1 �,CCORllA,NCE y�r�TH REGE� �D..
�ORTH �X�T�-1�� P�RSON C:�U.NZ��� t�t1;Ar.Tt-X DLPni:TMEN� � ULATZON
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