A40 276Aaaiicatlon Date: � 1 Jc� I�
Amount Patd• / • v
Recei 9
- � � ��l
Tax Man #: " ` -�
Par++�l �: Z.�tQ,
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- - � � � �T�i'�� - .:
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. APPLlCA710N FOR SERVICES . •
1) Permit requested by: (Ownedagent/prospective owner): 2�ec�na r C�
Home Phone: �S'� �t 3 S" 4's �f - Address; c� =
8uslness Phone: G( �, � Ho �'S/ � 8' .� � � a Y' � o r d
2) Name and address of currEnt awnec S a,ti �� S � lx� -�
3j -Prope�ty Description: Lot size: Township:
Directions to the property,(Induding road names and
c.�—�—
Lot# -2
4) proposed Use and Stnu:ture DescriPtion: answer eact� af the following questions: i �
._. ' a)- Proposed _,_, E�sting , Type af Structure: � c a r C� G r a��—_ Width:� �pth:�_
..• b) Number c5f Bedrooms:' . Number of occupants or people to be ed: -
. �' c) Basemer� Yes_,�No ,_ i�il there be piumbing in the basement? _
' � . d) 6a.rbaga Oisposai: lfes , No _ . � .
5) Water Supply Type: Private /(new _ or existin��� Pubiic . Communiiy ,$pring
. � Are any wetis on adjoining property? Yes_, No _ tf yes, piease indicate approximate locatiori on the
� 'site pian. � �
6) Do� your pro�riy cantain previousfy identifled jurisdlctlorral wetiands? Yes_ No
PLEASE NOTE THE FOLLOWiNG: '
➢ A PLAT OF THE PROPEiZTY OR SiTE PLAN MU8T BE SUBMITTED WlTH THIS APP�..ICATION.
➢ PROPERTY UNES AND CORNERS MUST BE CLEARLY MARi�D. •,
➢ THE.PROPOSED LOCATI�N OF ALL STRUCTURES MUST BE STA(� OR FLAGGED.
➢ THE SITE MUS'� BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMEiVT
STAFP. ' . �
1 hereby make applicatton.to the. Person County Health Departrnent for a siie evaivation for the on-site sawage disPosal
system for the above-descrii�ed proQertY• 1 agree that the corrte�rts of this applicatian are true and represent the maximum
facii'fiss to be piac�d on the property. i understand if the siie is aitered ar the intended use ct�anges, the permit shail
becam 'nvalid.
������� � -' l-�v � �
Owner or Legai Represerrta�ve • Date
PC2iD. re+r. �6127/U2
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�uaid��g A�da�on5/ 1@�ob�i� �o�e Re�la���ae��
Tax Map #:��
Approval Requested for:
Parcel#: Z7(e
�t Mobile Home Replacement
�/ Building Addition
Applicant Name: �D
Address: k0 .
b G
Phone #'s: 5�.��f .9�9 - 7y0 -8128 '
✓
Permit Located: Yes No
Installation Date: (¢- 2- 99 Design flow: 3(�D (gpd)
Cturent Contract with Certified erator on file (if required):
Water Supply: Well Public or Community
Wastewater system shows no visual evidence of failure on: (� ' Z 0� D(.Q (��)
(Applicant's signature if site visit is not required)
Comments:
� i�o�e�lac�ffient Appr�ee�
. 4, � Zo ��
Envir ental Health Specialist - Date
11/15/OS
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J� -���3]L'a@�rn iemm �E'Il�.�.�.1L ��O�..LLU�JL3
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SITE S1�TC�I
Taa Ma.p # �D Pa:�cel # 2?�O
Section/Lot# /
. Ce'�'�
Date .
System cumponents re�resent a�iproximate �contours only: The contractor must, fTag the system prior to
beginning the installation to insure thactpro�bergrade is maintained
u
. .�� ~ � A�a�J�
�cale: 7 JC��
PGHD, rev. 09/12/01
02/08/1999 13:49 �9i1799 PLANMING AND ZONING
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B 2946
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT 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 # A� Parcel # � 7�
Zoning Township Fct � �'�C/
Owner/Contractor S�MM ✓ /�a�,.�:.�r Date S- �� - 99
Location/Address
S.R.#
Subdivision Name Q k �' oc. c��cs Lot# /
� SEWAGE SYSTEM SPECIFICATIONS
Repair�r�,�, Z"�,w,��,1,ot Area %�� A� Size of Tank /400
SFD � - Mobile Home _� Size of Pump Tank eF�%r
Business # of Bedrooms_� Nitrification Line NUU �X 3�
Max Depth Trenches �y "
Permits may be voided if site is
Well and Septic Layout by �,
Comments: See co:��' ��!
or intended use changed.
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Date �- 2- 9q Installed byG'ann��.. y�,F� 13�os Approved by.
Well Permit Paid � WELL SYSTEM SPECIFICATIONS
Semi-Public
Slab
Public Replacement Air Vent ,/
Site Approved Required Well
Well Head Approved — Well Tag ��_/
Grouting Approved �/3� ►�{ (, - � -9 9 �o:Se l�� b
Comments:
? � ,�v -i -�
7►� �F (� -�,� 9�
,�� — �GY
Date '— Installed by , 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 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 Ol/95 rev.l.l
P.C. 10, P. 18-G
e
�SITE
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�' MACNETIC t� 4> > � 4 �
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1140 ALLENS
, � LEVEL
WILLIAAI L. HUFF � � �
` D.B. 212, P. 873 0 ��Cj
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1140 ALLENS
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WILLIAAI L. HUFF � \ �
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Date: '
Owner. � � S.p�►�v,
Location/Directions:
Subdivision Name:
Drilling Contractor:
. . . . ... . . - . _ ......... .
PERSON COUNTY ENVIROIIMENTAL HEALTH
WELL LOG
SR#
Distance from Nearest Properry Line r� Distance from Source of
Pollution . �O 0 `
Total Dep.th: 2 2 O Ft. Yield: 3 GPM S tatic Water Level ^
�_Ft.
Water Bearing Zones: Depth QA F� � 2�F� Ft� ��.
Casing: Depth: From C� to�U �Ft. Diameter:_�__�ches
TYPE: Steel � Galvanizeci Steel �
If Steel, does owner approve: Yes No
� Weight�: � Thickness: l�r Height�Above Ground: 6 t% Inches
Drive Shoe: Yes ✓ No
Were Problems Encountered in Setting the Casing? Yes No ✓
If "yes" give r�ason:
Grout: Type: I�Teat SandJCement_ ✓ Concrete
Annular. Space Width Inches
Water in Annular Space: Yes No
_ . Method: Pumped . . �Pr;ssure � � Pourzd� �_ . . • •, - : -
Depth: From O to �, c� Ft. � �
Materials Used: No. Bags Portland Cemenc Weight of .1 bag_lbs.
If mixtuie (sand, gravel; cuttings) - Ratio: to
�ID Plates: Yes ✓ No � � � •� � �
�� 4 x 4 slab Ye:s�rNo
I HEREBY CERTIFY THAT THE ABOVE INFORMr1TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH gy�THE PERSO�t C��i�'1'Y HEALTH DEPARTMENT. �
.� �
�Signature of Contractor atc
9
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