A40 312Amount paid ���'�O
Receipt li �
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Permit for New Well
Renlace Exis[ing Well
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�ermit requested by: . 7. Dimensions or Proposed tructure:
owner/nrnrnP�tive' ownerl2gCIIi: ldfh:
`�-� -- " au� � Depch:
„ aa_e��. _/� �D �
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ome Phone #:__��G% U/1%S- � -73
usiness Phone #: -� ����Ne4�r
Name and address of current owner:
� �%��'J7n /� /��
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. Property Des ription: Lot ize: -
�I'ax Mag#:
Parcel#: .
Township:
�
a¢ 5. Directions to
� ame�ls,�tc.
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� �.� -rav�
� operty: State d#& Road
► ,� � Rcl. ��ch�on
✓►.� (��. �' ✓c�s �� �1 �t
8. Wha[ type (if any, additions, expansions, or
replacemen[ is anticipated to the structure or facility
that this sewage disposai system is intended to serve?
� r� v c�.�e .�n. ;� 1�. � m�. -� �> r
_ 9. Water s pply ty pe:
� private public ❑ community ❑ spring ❑ p
_ Are any wells on adjoining property?Yes �No
If so, identify location: i fl �►' ��" � ho��
�r� �✓nrrl �-� p�nne��!
10. T�pe of structurelfacility: Proposed: DExisting:
Type of dwelling: ,,_f
House: ❑ Mobile Home: L�1 Business: ❑
Type of business:
Number of Employees:=—.
Number of bedrooms: .�—
Garbage Disposal? Yes ❑ No �
Basement? Yes ❑ NoQ�If so, # of basement fixtu
..,.L_. --�
6. Number of occupants or peopie •
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORI�IERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PersOn County Health Depat'tment for a site evaluation for the on
sewage disposal system for the above described property. I agree that the contents of this application are tn
and represent the maximum facilities to be placed on the property. I understand if the site is altered or the
intended use changes, the permit shall become invalid. I understand thatu ders[and hat in the ev nt havc
issued, I must present a survey plat of the property to the Health Dept. I
delivered a survey plat of the property to the Health Dept. wi[hin 60 DAYS after the date of the evaluatton
� the site by the Health Dept., this application shall become void and all fees paid forfeited.
W
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PERSON COUNTY HEALTH DEPARTMENT
WELL EiND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
g 2710
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 / L�� Parcel # —Q� '-3 � �
Zoning Township ��Q �'ve�
Owner/Contractor s Nd, NN�N ��� Date �-/ -99
,i -
Location/Address /S S, a ,� ,� .�o s .�
��q�� ���;� 1a70 P��.�S i ���.� /?�J. S.R.#
Subdivision Name _ � Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area �, ��j a• Size of Tank J000
SFD ✓ Mobile Home Size of Pump Tank �d
Business # of Bedrooms a Nitrification Line �7D �X3
Max Depth Trenches /8'�
Permits may be voided if
Well and Septic Layout by_
Comments: � �o
Y'o . ;�+s al�e��o✓. ,.
Date
ell
ell
L/�f �EPoi�
altered or intended use chan
s�a/,
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Installed b}� Approved by
❑ WELL SYSTEM SPECIFICATIONS F Xis .�
Installed by.
-' IRequired Slab
Air Vent
Requi� Well Lo
Tag
Approved by.
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1�/e �,
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 i�formation
contained in the application. The enviro�mental 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\permit.sam O1/95 rev.l.l
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3) Praperty D'escrdption: l.ot siz� I. o �Taumsf�ip: a�Y •` Sui�sion: Lot#
Directicns to ths
on R�c(h-t
Proposad llss and S�ruclun�crtption: ans�r ead� of the foilowing ques�On� •
a) pt�oposed _, E�dshing Type,of Strudur� !'%¢� �-� �P� �
b) Numi�er ofi B�room�-. �, Number af cccupanl� or peopie to be senrec� 2 •� X�� t
c) Ba�n�� Yes _, No ,y�Ni� tttera be ptu�nbing in ttte t�emeni? �� �
d) Gattiage Dispasat Yes,� No _ ' �-� V ► ►.� � '�� � � '� �s,�
Waber Sup�y 7j�p� Privafie �t�ew _ ar ,�, Pub�C_, Cc�utumi�Y ��_. -
Are• a n y r�lls an ad l� m 9 P� Y? Yes�o _ if ye.�, pi�se �e aPP� loc�ion an the s�e pfan.
Does #Ite pr+op�rty cmntain �reviowiy ident�ted jur�ai �? Yes _ No �
Pl,.EASE AIOTE TNE FOLLOWING•
' 9 A PLAT OF TF� PROP�TY' OR St'i'E Pl,rAN 11ftlST BE SUBiflTiE� WRE1 THIS AI'PL1Cp►TtCi�:
� i�ROPEi't7Y WdES AND CORNERS A�1ST BE CL.EARtY YAR�. .
➢ THE PROPOS� LOCATION OF ALL 9TRUCTURES 1ill.ST 8E STAK� OR RAC�. • -
9 THE SiTE B1UST BE READILY ��1Bi.� FORl1A1 E4lALU�►T�N BY THE HE�1LTl; DE�l1�iT ST.4F�.
i• here� m�Ce ap�on to the Pe�soa County H� �e�artrr�nt for a s�e �va�On tar the ot�-� �9e ��
system ior the abave-des�bed propeKy. 1 agree that the con�nts af this appQcatton are true and represet� the �usm
'Fa�tles bn be pla�d on the PtoperiY• I under.�and ii the s�e is aiteseci ar the irrt�ded use changes, the pemvi shail
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��-�`� PERSON COUNTY HEALTH DEPARTMENT
CATION IlVIPROVEMENT PERMIT
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WELL AND SEWAGE SITE, LO
Ta�c Map # ��p Parcel # 3 � �
Zoning L Township
Owner/Contractor ��,cG 4 �k�i�'�1��✓� Date � �
Locatio l��d� ss�-
Subdivision Name
Iayout
Lot#
S.R.#
as �iiea
• ii
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w��,� ��- g�es u�d�,-
Q��-E;D� .�� a o��s���.
o.� a-� �� 5�- s-��.
�c�C� t ( W � .�� �l.�ci�c s�t (
Qv� V'e-` Cu��wee� -�•rp,n.c�Ps,
SEWAGE SYSTEM SPECIFICATIONS
Lot Area
Mobile Home
# of Bedrooms_�_
Size of Tank
Size of Pump Tank
Nitrification Line_
Max Depth Trenches
0
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or intended use changed.
Well and Septic Layou y
Comments: I � �� � �
Date Installed by
Site Approved
Well Head Approved
Grouting Approved_
Comments: .
Date
Approved by
WELL SYSTEM SPECIFICA'
Semi-Public
Installed by
�i�Vent
Required Well Lo�
Well Tag
Approved by
TI ' rt is based in part on information provided the homeowner or his/her representative in the application submitted for this peimit. The �
enwomnental health specialist is not responsible for false or misleading infortnation contained in the application. The environtnental health spec�alist
is also not responsible for concealed conditions on the propeRy or for statetnents in this repoR that may have resulted from false or misleading
statements provided to him in the applicatioa Neither Person County nor the environmental health specialist wazrants that the septic tank system will
coatinue to function satisfadorily in the future or that the water supply will remain potable. c:\amipro�pemvtsam O 1/95 rev.1.0
ORIGINAL