A40 29ANo. of persons to be serve� Bedrooms 1,(2�3, 4.
Additional appliances to be used: Disposal, dishwasher, w�hing�
machine
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Recommended• Septic tanl � i
Nitrification line: �''`�' x � '
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line must be inspected and
approved by a member of the District Health Deparfinent staff before
any portion of the installation is covered.
Date Approved: � � � -� �
By:
Countersigned
Signe�
Sanitarian
O. David Garvin, M.D., M.P.H.
District Fiealth Officer -
(Over)
/o �tn,
NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on
adjacent property, etc. Write in measurements in order that installations may be located at later
date.
&UGGESTED INSTALLATION (Date ) FINAL INSTAI,LATION (Date )
(Road or Street) (Road or Street)
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PERSON COUN"rY HEAL`TH D�PARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
Tax Map # ,�0 Parcel # 2af�'
Zoning Township �/a �'u�/
Owner/Contractor � E. Nic o -- Date �-/?- 9�:
Location/Address a �3p �/� � �'v�� G'►' f� -
— S.R.#
ision Name
Lot#
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altere or intended use changed.
Well and Septic Layout by � i-� � c�S
Comments:
Date
Installed by
Approved by
WELL SYSTEM SPECIFICATIONS
dividual Semi-Public Required Slab
�blic Replacement Air Vent
te Approved Required Well Lo�
ell Head Approved Well Tag
. . , i r . �„_�i�A�a „�,�
Comments:
A 1512
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 Uus permit. The
environmental health specialisl is not responsible for false or misleading infotmation 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�pemritsam O1/95 rev.1.0
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