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Improvemencs P�r:rtic �...stab(ished/Reeorded L,oc) �_
Imczsovements Pc:znic (Unreeorded Lot)
imo�v�emczcs ?erznit (hlobile Home Replace)
Imqrovcmcacs Pcmic (Addition) �
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Dace
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� :c•_ �:1�•� ... • � --:.��....i•'`•: �,�'
n of ::ziscing S;1stcm (Loan Closin
� Re�aidRcplace c:.iscing Se�tie Systcm
� ?c:r,zit for New �N�! t
_ Reptac: Existing Well
_ Bacteria � _ Chemical � _ Petroleum � ?csticidc ( _.. Lcad
. nac tycc (if ar.y. a itions, expansions, or
rc�taeemenc is ar.tici�aced to t'r.e scruc:�ce o: facilit�
�`la: t;�iS s���va;e �iseCSal systerrt ►5 cnceadrV co SeN�'
/l ,? 1,� � .
9. Wate: r,�:^-,° Iy t5 �e:
privatc �pub(ic � commur.icy Q s�Rn; G
?,:e any wc?ls on adjoining gropar,y?Yes G� No �,.�. '
Lf so. idencify tocat:cn:
I0. Type oc s:ructureJfaciliry: Proposed: QExisting: !
Tyge ar dwell�g:
�iouse: ��Mobiie Hame: Q Susincss: 0
Typc of basincss:
Number of Em lo e:s:
Nur�ber of bcdroo�ms: ,p •� ��
Cr�rf�a3�I�sp o
�`` r`i �af b�scment fixtur�
�Ll��.m.�t9 V�c NAit�'Tf _ Q_
CLEARLY STAF� ALL C4�tNERS QF TSE PR4PER'PY AI�ID THE C0�`IERS OF ALL
PR�POSED ST'RUC1'URES.
I hcreby makc applicacion co che Person COunty �ealth Department for a sitc evaluation for thc on•s
sewage dispasat syscem for the aiwve described ptoperty. I agrce that thc coR�cats of chis application ate truc
and represcnt the maximum facilidcs to be placcd on the progcrty. I understand if thc site is� altercd or the
incended use changes. the pernut shall beeome ittvaIid. I uaderstatid that befo�e an Improvcmcnts Percnit can
issued, I must pccsent a sucvcy pl�t of the pcopeRy to the Health Depc. I undersiand that in the evene I hava n
deiivcced a survcy plat of the pcoperty to the Health DepG within 60 DAYS after thc datc oE thc evaluatio� ot
the site by chc Hcalth Deg�, th� application shali becomc void and afl fccs paid forfcitcd.
10 3�tid
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Owner er Authoriud Agent
9NINOZ QNd �NINNti�d
66LTL6S 6b�Ei 666Z/80/Z0
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�' PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Reiocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # /� � d
Zoning
Owner/Contractor k. .,r�c
Location/Address �',�
G r� �� /C J`.
Subdivision Name /7�
Parcel # � � I
Townshi�Q�
Date -.�Z- 9�
�S7S. .�%�'1' �P
S.R.#
Lot# "� � �.� � �,
SEWAGE SYSTEM SPECIFICATIONS Rc,co
Repair Lot Area %� �• Size of Tank /�K�
SFD Mobile Home ✓ Size of Pump Tank
Business # of Bedrooms� Nitrification Line !�/Q�D �X�''
Max Depth Trenches .Z�l "
Permits may be voided if Js'� is alt re or intended use changed.
Well and Septic Layout by �J c•r�--
Comments,� v�/' ,��; d� G'o.�.s��y t:lw -�
�� zl �'NS �.. � d, � ���
Date_�p-�- _ Installed b_y %�1, j,p/,O(S Approved b_y;
Well Permit Paid WELL SYSTEM SPECIFICATIONS
Semi-Public
Public
Site Approved
Well Head Approved
Grouting Approved_
Comments:
Required Slab ' '
Air Vent -
Required Well Lo �/
Well Tag l." � �-
Date T �' � 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 mislea�ding 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 continue to functio�
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
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PERSON COUNTY ENVIBONMENTAL HEALTH
. � ` � .
` •• WELL LOG '
Date: ' '
Owner. � . �'��V�� j��� �-I �r�i-� � SR#
.
Location/Duections: �
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Subdivision Nv�ne: _�A�`��� ,���� Lo[ # ?�
Drilling Contractor:�A"�t 1��[TEG / �'3��� t ��-r � -r-,����
WELL CONSTRUCTION --
Distance from Nearest Properry Lin� 1C� Distance from Source of
Pollution_ I.(� '
Toc.al Dep.th: �« _ Ft. Yi�ld:�__.___ GPM Static VVater Level______t=�.
Water Bearing Zones: Depth�(c� _Ft. Ft Ft�_�_�t,
Casing: Dept}I: From O to_�?�Ft. Diameter: / Inch�s
TYPE: Steel � Galvanized Steel _�
If Steel, does owner app:ove: Yes No
" Weighc: Thic};ness: •1�38 Height Above Ground: I�- Inches
Drive Shoe: Yes o
Were Problems Encountered in Serting the Casing? Yes No ./
If "yes" give r�ason:
Grout: Type: Neat Sand/Cement � Coricrete
Aruiular Space Width Inches
Water in Annular Space: Yes No
- -- Method: Pumped � - Pressure � � Poureri /� � � �. .
Depth: From C� :o �_� Ft. . .
MateriaLs Used: No. Bags Portland Cement Weight of .1 ba�_lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
�ID Plates: Yes �No � � •� �
�� 4 x 4 slab Yes—�No �
I HEREBY CERTIFY THAT THE ABOVE INFORM�1'IZON IS CORRECT AND THAT
THIS WELL WAS CONS�'RUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH By�THE PERSON C�Li�iTY HEALTH DEPARTMENT.
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ignaturc of Contractor D tc
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