A41 49�iealth Department
Water Supply and Sewage Disposal
IMPROVEMENTS PE IT No.
ate —
Owner:
Location:
_ a/s/.�1'�A'T�
line:
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years an3 shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
Date approved:
Well:
Sewage Disposal:
By:
<
Signed
Sanitarian
Counter-
signed
(Owner or his representative)
Certificate of Completion t
r �
Date Approved: ��� By: .-C `
nitarian
(OVER
Location of well and sewage disposal facilities sketched on back.
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Wnite in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots.
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Improvements Permit (Established/Recorded Lot) �_ Reinspection of Existing System (Loan Closing)
Improvements Permit (Unrecorded Lot)
Permit (Mobile Home Replace)
Permit (Addition)
Repair/Replace existing Septic System
Permit for New Well
_ Replace Existing Well
_ Bacteria � _ Chemical � _ Petroleum � _ Pesticide � _ Lead
1. Permit requested by: /�'! lCl��}CL R� Lf}ws 7. Dimensions or Proposed Structure:
owne prospective owner/agent: Width: �G � sz-"�r�'�= ���
ddress: ? Z� 1 f�UI�17[-� /Lt�[.tS � Depth: S/fl '
�`� «� ` �� �� 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 #: .3G y-Z� � �
usiness Phone #: s��'- /�Sl-8SS5"
2. Name and address of current owner: 9. Water supply type:
_ gsv�' private Q public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No ❑
If so, identify location:
3. Property Description: Lot size: �� 'i ��� •
,. Tax Map#: A-�y I 10. Type of structure/facility: Proposed: �Existing: ❑
' Parcel#: y S Type of dwelling:
Township: �� i iZiv� R- House: ❑ Mobile Home: ❑ Business: ❑
5. Directions to property: State Road #& Road Type of business:
ames, etc. Number of Employees:
, Z ,,,, � � s � ;�S Number of bedrooms:
� <<� � � � arbage Disposal? Yes ❑ No ❑
�� ,� -�- � � asement? Yes ❑ No ❑ If so, # of basement fixtures:
6. Number of occupants or people to be served:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND TH� CuxNr:x� ur� aLL
PROPOSED STRUCTURES.
I hereby make application to the Person 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 Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the Health Dept. within 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.
Signed Owner or Authorized Agent
t • • y
Permit Issued ❑ Signature
Permit Denied ❑
Plat Observed ❑
Date
;; ; ;: FACTOKS-S1IEEVALVA710N ;:: <: ;:' AREA1 .. ;:; `: AREA2 ;;i. . ;;: ' AREpi3 AitEAd
_ _ _ .._ _. .
1. SLAPE (96) S S S S
PS PS PS PS
U U U U
2. SOILTEXTVRE(12-36IN.) S S S S
(SANDY, LOAMY, CLAYEY. NOTE 2:1 CLAS� PS PS PS PS
U U U U
3. SOIL STRUCTURE (12-361N.) S S S S
(CLAYEY SOII.S) PS PS PS PS
U U U ' U
4. SOIL DEPTH (IN.) S S S S
PS PS PS PS
U U U U
5. RESTRIC77VEHORiZONS(IN.) S S S S
(IMPERVIOUS STRATA. ROCK) PS PS PS PS
U U U U
6. SOIL DRAINAG&GROUNDWA'IER S S S S
(EX7'ERNAL & INiERNAL) PS PS PS PS
U U U U
7. SOIL PERh1EA8iLTfY S S S S
(PERCOLOATION RATE) PS PS PS PS
U U U U
8. AVAII.ABLE SPACE S S S S
PS PS PS PS
U U U U
9. STCE CLASSIFICATION(SEE BE(.OW)
SO1L SERIES
S-SUITABLE PS-PROVISIONALLY SUITADLE U-UNSUI'CABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.) C:WNIPRO�DOCSIAPPSEC.SMFlNANCE.PC
PERSON COUNTY HEALTH DEPARTMENT ' C�' 6�
WELL AND SEWAGE SITE, LOCATION IMPROVEMEN�T, PERMIT
Tax Map # � �� Parcel # y7
Zoning Township FU9- i � VC' �
Owner/Contractor � i.V � Date R' �1 ! �95-
Location/Address �n? 3 f �ut-r,i (� M%/( 5
S.R.#
Subdivision Name Lot#.
Layout
�E P� c' r►� ��- t,v ���1-ten -f-o Q.110 u
j�ra�� �� � on w i�t�. No
C�ja�q,E'S 'f"D �'1Cr'�r7•�!� ��'l;C
0
sy�-e��
As Installed
�� �`AG�GIi-l�o�
J �
I�ouS E
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area �t �t % f�fP Size of Tank_�X�54► n� /�ad
SFD Mobile Home Size of Pump Tank �
Business # of Bedrooms Nitrification Line �tci5�-i�`r-� 3� X3
�a e ��Gt i�f-ian Max Depth Trenches
Permit Void afte 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is alter d or in ded use c
Well and Septic Layout by _
Comments:
� Date�
a
�
� Well Perm
�
E� Individua
Publ ic
Site pro�
W Head
outing A
omments•
Date
Installed by %ti°�/�S�e�{ioll Approved by.
❑ ELL SYSi M SPECI CATIQN
mi-Public R uired Sl �
eplaceme ir Vent
Requi d Well g _
ed W Ta�
led by
_Appr�dved by
This rep �s based in part 6n information pr�vided the homeowner or his/heF.�epresentati m the app�lcation submitted for his pertnit. The
environ ental health specialist is not responsible for false or misleading information cont 'tned in the application. The envi nmental 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 applicadon. Neither Person County nor the environmental health specialist wairants 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 01/95 rev.1.0