A40 30, � �� L P E �N`�.-r
9.� PERSON COUNTY HEALTH DEPARTMENT
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� WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
�_ n'"Tax Map # A�/(� Parcel # 30
Zoning Township F/at !� � vcr
Owner/Contractor Qet�y_�_f��l�SOn Date '8-,�5-�
Location/Address �p7o F/a.t R� Jer Ctiu�eh Road
S.R.#
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Subdivision Name . _ Lot#
A 1904
� SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area /�O AC Size of Tank
SFD Mobile Home Size of Pump Tank
Business # of Bedrooms Nitrification Line
Max Depth Trenches
Permit Void after 60 months.
Permits may be voided if site
Well and Septic Layout by �
Comments: _ , .
Date
Permit Void if not in compliance with zoning regulations.
p alte�ed qr inter,�ded use changed.
Approved by.
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 Approved by
This report is based in part on infocmation provided the homeowner or his/her representative in the application submitted for Uus pemut The
rnvirorunental 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
statetnents provided to him in the application. Neither Person County nor the environmental health specialist wazrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�pernutsam Ol/95 rev.1.0
ORIGINAL
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