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A40 99M a� J+� Amount paid 16�' Receipt .4l '�r� � (o�� � � APPLICATION rOR S�RViC�S Improvements Permit-(Established/Recorded Lot) ImpFovements Permit (Unrecorded Lot) improvements Permit (Mobile Home Replace) Improvements Permit (Addition) � H., : . >: � O :., � � . _ Bacteria � a w U � a ��-�%'�% / Date _ Reinspection of Existing System (Loan Closing) Repair/Replace existing Septic System _ Permit for New Well _ Replace Existing Well .,.: ..._. . . _....-- _ _ Chemical _ Petroleum _ Pesticide _ Lead 1. Permit requested by: . 7. Dimensions or Proposed Structure: owner/prospective owner/a�:�� �o�vq Width: �' e�t�t�P��• `�/� Ao,�.u�"��,�, �b. vUr.:�,;- S'/,� Depth: - �' - ���at.o �� �?s'T 3 8. What type (if any, additions, expansions, or replacement is anticipated to the structure or facility that this sewage disposal system is intended to serve? ome Phone #: �1 R ' �3 3 usiness Phone #: �7 � .�5�� Name and addre�s of current owner: 9. Water supply t}'ge: �.��q. �� �,'� �� q.,;,;�t private �.. public ❑ community ❑ spring ❑ �S� ..�p ��F��S�y,Q -(��� _ Are any wells on adjoining property?Yes ❑ No Q. �,�; im�-,r.6 �� ��G 28�1-y _ If so, identify location: . Property Description: Lot size: � d�a . Tax Map#: � - �O � Parcel#: �ef Township: �l./-�� R < i � ��2 Directions to property: State Road #& Road ames,�tc. � t �d � m► ! ((� — ! �1' /s ( ���H ��� f� G�k Number of occupants or '�'7 � /�f�p/�x S -G 7f � L o F /�.�n `t To� �.�co%�v,���, to be served: S 10. Type of structurelfacility: Proposed: �Existing: Q Type of dwelling: House:�` Mobile Home: C� Business: ❑ Type of business: Number of Employees: Number of bedrooms: 3 — Garbage Disposal? Yes ❑ No � Basement? Yes ❑ No� If so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AI�ID THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the Pet'sOn COunty Health Department for a site evaluation for the on-site sewage disposal system for the above described property. I agree that the contents of this application are true 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 that before an Lnprovements Permit can be issued, I must present a survey plat of the propec[y to the Health Dept. I understand that in the event I have not delivered a survey plat of the property to the Health Dept. wichin 60 DAYS after the date of the evaluation of the site by the Health Dept., this application shall become void and all fees paid forfeited. Permit Issued ❑ Permit Denied ❑ Plat Observed ❑ Signature ► Date � � e s ., i:. � FAC�nRS-STTE �VALUA770Tf .. � �; s ! xx: "' r � " ARF�4l ,ryARFJ�2 z . ARF'Jt 3 " w .: >::A�A 4 �z z , ; . a. -.,..: x... ..,; , ,,,:. . . , _.;.,. . ...._ �.,::..: „ .Y:;; _� _.__. , , :. _. ...:.: 1. SIAPE(%) S S S S PS PS PS PS U U U U 2 SOiL7EX�lJRE(12-36IN.) S 5 S S (SANDY, LOAMY. CIAYEY. NOTE 2:1 CLA1� PS PS PS PS ' � U U U 3. SOtLS7TtlICTL1RE(12-361N.) S S S S (CLAYEY SOiLS) PS PS PS PS U U U U g 5 S S 3. SOILDEF77i (IN.) PS ps pg PS U U U U S. RESTRICf7VE HOAIZONS (iN.) 5 S S � S � (QvfPERVIOLS STRATA, ROCK) PS PS PS ps U U U U 6� SOILDRAINAGFlGROUNDWATER S S S S (FJCCERNAL& WfFANAL.) PS PS PS PS U U U U 1. SOILPERMFJIBII.ITY S S S S (PFACOCAATION RATE� PS PS PS PS U U U U S. AVAIL�BLESPACE S S S S, PS PS PS PS v v v u v. arrscuss�c�noNcsEEs�.ow� SOIL SERIES � S-SUITADLE PS-PROYlS10NALLYSUITAIIl.E U-UNSlJ1TABLE RECOMMENDATI ONS/COMMENTS : SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill \ `� '`� ; c� . ' � �' `'' � \ � � �� ,.� � � ��� �� �' �'`► � �, ' � � � � � � � � � � o �` � '�'�, w �' c � �� � � x� '� . � � � � '� � `` '' �. � d .�' � � � �- � � � N ` '� � . C� � . _ � '' � •� , � _ � .� � ' i , � 'V� � u -� � • �' � , W � � �� � � � „ ,,�, � ,� � � � •�� ,�C� � , � 0' .y � �+� � '� � j , �� 4 � .� �'�`�� y ��-. e ; �� ,� � � �� ��� � �y � . � ��� � �, ,1�� � �y !� , �`My � � `; ;i� . �� � :� ` �,� ,� � ���� � � �`� ,� f� ,.� '�a J,� 4 q . • \f � �� �� � � � 4; • �� � �� � `J 1� � Zi r'-° � � � �� � � . � .ti`� �r a��� �'�',i� � ,,6 . .� � �� � o � ,� ' 4� ¢ � ��� T��. � O �+ � �� s � •,� '� • `\ � � ^ o� �� �J � � � ` �� 'Q � ;14� ' y'�'.,� `:� � . . � ,P � �1b � �oi� �!`sJ � � .�1 �r � , '�'�qr ba A '�q� � .,� �. �� ��� , ;� �� . ./� � ` � • �i . �- .y d° % ��p,. _ ,�, �� -Y � Ay �� �7• ',,�, r'r �� ; � "� • � ' d'�� t � � � h f � �i j �' ,y � ' ; �► r% ,b r� ''t', � �t� �a � � .� /_ ,�� � � * ...... � � � a W U � a � �� B 1968 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERNIIT Not for waste water system construction. No permit(s) for Construction Location or Relocation Activity shail be issued until Authorization for waste water system construction has been issued. Tax Map # %7 �'Iv Parcel # �� Zoning Township �o�,+ � ��✓ Owner/Contractor i'.'�o b a y a v. % Date � I— a.5 �' �i �7 Location/Address S.R.# Subdivision Name [d t 0 r� i a l �S �a�-e 5 Lot# � SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area 0 Oo c1 � Size of Tank�n(') SFD l� � Mobile Home Size of Pump Tank N�!- Business # of Bedrooms 3 Nitrification Line 3 4 3 Max Depth Trenches �4 " Permits may be voided if Well and Septic Layout by_ Comments:��,�f 1 LL� �D�anzr�'y L.i1�.s. Jie� Date Installe by is altered or I Op-�� use chan �� Approved by ell Permit Paid ❑ WELL SYSTEM SPECIFICATIONS Individual t-J Semi-Public Required Slab Public Replacement Air Vent Site Approved Required Well Log Well Head Approved Well Tag Grouting Approved Comments: Date Installed by. Approved by /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 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. c:\amipro\permit.sam O1/95 rev.l.l � `/ y / � ' � •' \ b�` c�. • 4 . .�, � 'i'r, '�o. %, � � �,: �✓`(( o,�a �- ,,� �� • �,. . �� ' ��� G y `� k �, f � ' . �►� �� ti\ y �� d ` , !` �!, �!` `sc � (� � ,�, r � 4� ' " \� � ���� , V � �• _ ` � v TnKy v . ` � V � '�\' �� � - �� Q� Y� � 0 �. � �� � � "� � .�v 4 . Q(� � X �7 �� � � . � X � 9d � � X '� C'G%� � � � �„ � 7 , � � • 9h�� �'y� � �i� �� . � �� � � � �. �� � �� � ♦ Q ` � � T1. . r� y � � . . "�'` , �` � � � �� .