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Receipt
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Date
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I. Permit requested by: . . �,,�,, 7. Dimensions o � Proposed Stn�cture: �
owner/prospeccive owner/agent: � � �-'�t� �B _ � Dedth: � �'—`
Address: 311 .� �-.f�SAI� ST' `�_— p
� i1U21�FflM l�1 C- �'�1� �' 8. Whal type (if any, additions, expansions, or
replacement is anticipaled �o the slructure or facilicy
that this sewage disposal system is "intended to serve?
Home Phone #t: �'3� "�� O
usiness Phone �: _ _
2. Name and address of current owner: _
�('�,rv�o � /' � (a �� lsJ o �
. Property Description: Lot size: 1� d0 �C
. Tax Map#: l� �D -
Pa�cel�: ��8
Township: �1.�-i 2�V=YL.
�. Directions.to property: State Road #& Road
�ames, �c.
•N ��n.o
�f`u� (Lf- o�l
'7A��IOC� �C
� ySo r "�tKE lS7 5
R,D. u �1-t' .
2� Lv o N LE�
9.��Water s ply t)'pe:
private public❑ community ❑ spring❑
Are any wells on adjoining property?Yes ❑ No �
IIf so, identify location:
10. Type of stcuc[urelfacility: Proposed: l�Exis[ing: Q i
Type oF dwellin :
i
g �
House:❑ Mobite Home: Business: ❑ I
Type of business: �
Number of Employees:
Number of bedrooms: �
Garbage.Disposal? Yes, �[�, �No B�
Basement? Yes❑ Nol�'it so, # oF basement fixtures:
6. Number of occupants or people lo be senred: J
CLEARI;X STAKE ALL CORNERS OF THE PROPERTX AND THE CORNERS OF ALL
PROPOSED ST�tUC�.'URFS•
I hereby make application to lhe Pet'SOIi COi1IlEy T�ealth DePartlrient for a site evaluation for the on-si:�
sewage disposal system for the above desccibed property. I agree that the contents of th�s application are true
and�represent the maximum facililies to be placed on the property. I understand iF the site is altered or t�e
intended use changes, the pecmit shall become invalid. ' I understand that before an Improvements Permi[ can t
issued., I must prescnt a survey plat of the propecty to,the Health Dept. I understand that in the event I have nc.
delivered a survey plal of lhc property to.the Health Dept.�witbin 60 DAXS afeec the date of the evaluation of
the site�by the �-Iealth Dcpt., lhis application shall bccome vofid�and all fces paid forfeited.
,.
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B 3136
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 been issued.
Tax Map # f } y�
Zoning
Owner/Contractor i lb��'t Crabb
Location/Address I�S7 S � on
c�l�d L�t O n( L) f � thc (-�
Subdivision Name C�.K r i dq c,
Parcel # 3� �
Township 1=1at IZi ✓ cr
Date I D a3-99
f-it.�FF �oGd rnto Q'xKr�d�� /}crcS
S.R.#
Lot# 30
�nn a �`�c SEWAGE SYSTEM SPECIFICATIONS
Repair iFneccssQ�y Lot Area �. Q(� /-�C Size of Tank I,00� C�a ( f On
SFD Mobile Home�_ Size of Pump Tank
Business # of Bedrooms 3 Nitrification Line 400')C 3'
Max Depth Trenches I � "
Permits may be voided if
Well and Septic Layout by_
Comments: � /Y�e�� �')
�_ .
Date
intended use changed.
��c FOr �a�}roc.ct�' �e.� �'%1 Fo� Cc�tc��t,'�^s
Well Permit Paid WELL SYSTEM SPECIFICATIONS
Individual�_Semi-Public Required Slab -
Public 1Replacement Air Vent
Site Approved �� Required Well L�� i/ :, �} �} � �-19 -`� �t
Well Head Approved Well Tag �
Grouting Approved I I� 1 q-g 4 c� 5e- �J �,�j
Comments: ISee�p (,� e I I (A p' PI �.�5 Fr�m �
FOunda•Eivn /�'aFF ip zr-t lin
Date I o?-;3- �J �' Installed by
c S y,g-(,� m, ca7S' F�o m b u � ld 1�
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 warraots that the septic tank system will conti�ue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amiprolpermit.sam O1/95 rev.l.l
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PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
... r, • ' .
Date: I� ' �
Ow ai r. ����-, i���� � SR#
Loc on/Duections:
Subdivision �Name: -� Ij l_ �. A�i -,�,� Lot # p
Drilling Contractor: �_�- �
WELL CONSTRUCTION —
Distance from Nearest Properry Lin� h Distance from Source of
Pollution O '
Total Dep.th:- ��_ Ft. Yield: �}G GPM Static Water Level
-2-�_}= �-
Water Bearing Zones: Dep[h �_!�t.9a � FL Ft�__T____�t.
Casing: Dept}i: From � tc��_Ft. Diameter:_ ( G/LI Inches
TYPE: Steel - GZlvanized Steel —�
If Steel, does ownerapp:ove: Yes No
� Weight: Thickness:�,l8� Height Above Ground: I� Inches
Drive Shoe: Yes ��to
Were Problems Encountered in Setting the Casing? Yes No /
If "yes" give r�ason:.
Grout: Type: Neat Sand/Cement � Concre[e
Annular Space Width Inches
Water in Annular Space: Yes No
_ .. Method: Pumped . . Pressure � � � Poured l- �. - � �. .
Depth: From CS to ZC3 Ft. � �
Materials Used: No. Bags Portland �ement Weight of .1 bag_lbs.
If mixtuie (sand, gravel; cuttinos) - Ratio: to
�ID Plates: Yes � No � � •� �
�� 4 x 4 slab Yes -� No �
u
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND TH AT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSO�I C�Li�'1'Y HEALTH DEPARTMENT.
� -- ---
ignature of Contractor Datc
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