A40 309�
, Amount �3Ld l.�O�co �� �o�s
, Raceip� r� ' �Of I �
' �$� 10 I I �1 APPL
�
O
,
�—�U� / i
Da te
�;� ' :�: r� �•� r�`:;�:���=,:�.'�:s� '='`�"' er lc s Requs�'e$�`�:�.;�'T '� .-=.'� :%-:?;:z.:'',. •'-:.��r'
��mprovemencs P�r-zic ("':scablishcd/Reeorded Loc) _ Reiaspee:ion oi �xiscing S;�stem (Loan Closing)
✓mtsrovements Pc :�nic (Unrecorded Lot) �_„_, RcpaiclReplace ez:stin; Se�cic System
jmcc4�emcics ?er-a:c {Nlabile fiome Reglace) �,,,,.,. Pc:r„ic foc New W�It
_ IcRprovc:ncncs Pcrnic (�ddition) � {_ Replac: Existing Well
_ � ac,eria � _ Chemical � _
� � .. it reques;ed 'oY: -
wnec p; vsgec:ive ownc: `�
.. acess: � H �.� f�; ���
P� �,C l7 D !'.^. /,
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;
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iomc Phanc R: .. �� ^! _ � �� / 'L,
lusiness Phone ;:
�
_ Petroleum � _ Pcscicidc f �Lcad
;l Dic�asions ar P�o;.osed Sc.^�. curc:
W icth: � — � `� �
Dc�ci:: • �
� W�zt ycc (if ar� �ddi� ns, cxpansions, or
rr�tae�r.^ene is aaciei,:ated co cre struc:�re o: �aeilicy
�.ac c^is �����a;e dis�esai system is intcadcc co serve�
���nF
�
. Nar.�.e and addre5s oi,c�rrent owncr. 9. Wat�; saroiy ty .e:
���' �n m�% ./� ���c � n 5 _ privatc ;r�ubiic ❑ communiry Q sprin; r
�� �/�� ���',�c� r�t /r /I'I ;[f� A:e any wells on adjoining grapery?Yes C No ��..'
��boro�,�r C ��� in3 If so. icencicy locatioa:
. Prooertv Descaotion: Lot siu:, • _ _
� Parc; I#: _ �
�
Township: F/� T .,�`'��✓�
� 5. � Dirc�tions co pcope:-cy: tata
� ames.�cc.
d �' y
� i % r
�
� & Raad
0
Number of occccpancs or peoQle to be served:
I0. Tyge e� s:ruccureJfaciliry: Proposed: QExisdng: !
Tyge a� dwellSng:
�:ou.se: ��Mobile Hame: Q Busincss: (�
Typc of busincss:
N�u �r oc Emalovees:
Number of �cdrooms: ._�_�
IVV��� ' ;r`'
CS Q��, �� 3Sf.iTiGQ� �1Xtllt�
CLEARLY STAI� ALL CORNERS OF THE FROPERTY AI�ID THE C0�`IERS 0� ALL
PROPOSED STRUCTURES.
I hereby make application to the Persoil COtlttty ��Ith Depat'tment fvc a site evaluacion for chc an•s
sewage disposai syscem for the above described ptoperty. I agrc� that thc eocc�cnts oE this application ate tntc
and ceprescnt the maximum facilitics to be placcd on the prvgerty. I understand if the site is� altercd or the
intended use changes, the pctmit shall betome it�valid. I understattd that beforo an Impcovomcnts Permit can
issued, I must present a survcy plet of tlte pcopeRy zo the Healch Depc. I undersiand that in the cvcac I hava n
deliveced at survey plac of the pcopecty to tha Health Dep� within 6Q DAYS after thc date oE thc evaluation o!
the sita by tiu Hcal�h Degc.. th� application shall becoma void and a!1 fccs paid forfcitcd.
�
z • �' cci Own�r or Authoriud Agcnt
t0 3�dd �JNINOZ QNti �NINN'��d 66LZL65 6b �ET 666Z/88/Z0
� ' �. �Z�°� . �o��
• ` ` �`
P�o_�-� ���
� �5�' PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
�
W
�
a
B 3137
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�7
Owner/Contractor rr��
Location/Address 15'7 5
��rd ��� on L r n�thc
Subdivision Name �lcikri
C��^
Parcel # 3� 1
Township F/c�t %' � V c.1-
5 �..orrfta MaSSc Date IU ��-99
t,FF ?Zoad i n�t0 Qo, k r i d4 � r4Cr-cs
S.R.#
Lot# 31
SEWAGE SYSTEM SPECIFICATIONS
Repair�nnOU'a;��'� Lot Area ���7A'C Size ofTank j,Oc�D Rallor?
SFD Mobile Home Size of Pump Tank
Business # of Bedrooms�_ Nitrification Line 400' X c3'
Max Depth Trenches a y"
Permits may be voided if�
Well and Septic Layout by_
Comments:
or intended use changed.
Date j/� 9- �Jq Installed by T�.,��f �i� Approved by
Well Permit Paid 0� WELL SYSTEM SPECIFICATIONS
Individual�_Semi-Public Required Slab �
Public Replacement Air Vent �
Site Approved Required Well Lo� —15- OoD
Well Head Approved �/ Well Tag ✓
Grouting Approved IJoi t,� � i NESSF.v d5�- 6i b �
Gomments: Kcc�,
lu` pFF oropc�
Date �—� OO
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.
\ami ro�permit.sam O1/95 rev.l.l
� � � —'� %`� .��d na-� t� ��t��
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01/12/20[)(� 1E�:30
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8044547843
EtNhdETT WELLDRILLING
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FERS;1l� CUUVj'Y E'tt`�J t10tr`1F:`; i�i• �IF�AI_'ff
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PAGE 04
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{',�sing� I)r�th: I�r���n �..._. tc� ..._..'...."_� - . .__,_ , _ ___
�i Y7'f=.: Steel � --�-�--•._._.�t. Uiametr� : ._ �_�5� .__, I>>� hes
.+._._Galvani7,c�1 S�e�! �
i( Siccl, dc�es owi�Pt an�rove: Yes � Nc� . ._. �
.
�'eighc�.l3,�1�__ ��l�ickn�ts� /�`fl .^� f iei ht Al�u���� (� ,
Ikive Shnc�: Yes � -- � .ro ir�ci� .._/� �cic;l�cs
�.Y_...._..� No `
��ere 1'r,�t�l��m� E:nr�,�m�erai in S�ctin�, the t�;:�ir�F,' �'es_ �N� ..r
lt '��•�s" �i;-,; ;,-.�on. _ � • � --
t;z ���,t: 'i�v}x�: ��1eat...►!�_._..... _ SancllG�men� .- - .. _ ,_. .__. _...,. - .�__
� ��:���c'i!'lC
Arintil�� SJ�acc Wi��tt�_ � Inc}�c•�_._... . . ._ _. � .
lyaler in Aruiulat Space: Yes �__ �o ✓
I1�f I}J0t1: PlIJRPf'�__,�.✓ �'r�ssu�e ' �.-�'oi��<<J
I)e���th: l�r�►in _ ..!> Ie, _��;.. __ �.i_ ._.�.. . . _ .
,ti1a�eTials llsni: No, Bags Portland i,erneti� 1l'ei�ht of 1 h,3�, �,�t,,.
If nsixturc i;��;��, gra�ci, cuttings) - J;��i�:` �� �.�
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[U �'lates: Xcs ✓ No .....�... ._.... ._..._
�� x 4 slab Yes ✓` No ��
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