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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT
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 #� y I Parcel # � J�
Zoning Township ��;{-�; ��,�
Owner/Contractor _ n� f� (� f' n Date -] - ot I-9�}
Location/Address � �'�Sou.�-1,� �rl �-� Q,�- �'1 Z.3I
S.R.#
Subdivision Name
Lot#
SEWAGE SYSTEM SPECIFICATIONS
pair Lot Area �� �`'(� C Size of Tank �'
D ✓ Mobile Home Size of Pump Tank
siness # of Bedrooms�_ Nitrification Line `x3' CsT1��- .3
Max Depth Trenches a c�►''
Permits may be voided if site is •ed or
Well and Septic L�yout by
Date �'� -4�t Installed
e changed.
Approved
S.
Welt Permit Paid LvJ' WELL SYSTEM SPECIFICATIONS
Individual ✓ Semi-Public Required Slab �
Public Replacement Air Vent
Site Approved Required Well Log �
Well Head Approved � Well Tag
Grouting Approved � ��`� }-�oSe �1 b �
Comments:
Date 1��$-� q Installed by
Approved by
This report is based in part on information provided the ho'tneowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
co�tained 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:\amiprolpermit.sam O1/95 rev.l.l
'. • AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: `� -o� I —Q�
TAX ViAP �: ��
IltiiPROVEI�IT PER��I�IIT �: ' 31
PARCEL �: �Z '�J
ow�xiowrr��° s x�xxEs�r-ra�rrvE: �c(1�D nv � bc'-4-o�1
LOCATION/�.DDRESS:
SUBDIVISION ti:�:�iE:
SECTION OR BLOCK:
N FOR CONSTRUCTI N ISSUED BY:
AUTHORIZATION ONDI'TIONS
LOT �:
1. The Wastewater system constiudion and installation must meet all of the conditions of the
a�ached site pI� and specifications as set forth in Im�rovemenu PermiL �,8,�) `�D . The
construction and installation must also meet alI appIicable rules and laws.
2. No portion ofthe Wastewater system shall be covered or placed iIIto use uuiil inspected and
approved by the Person Couaty Heatth Departme�t.
3. Any akeratic�s ia site or soil conditions (including struct�ue Iocations) or modific�ion in use,
design wastewater flow, ar v�iastewater characteristics as specified 'm the associated
improvemeai pezmii and applicatioq may void this authorization and assaciated permits.
4. Conditions:
Schedule 40 solid p,ioe over dams Keep septic 100 feet from any weI 10 feet from anv __
praperty line IS fcet from basemeat wall 5 fsex from anv vart of the house. Keefl well at _•;._.,_ .
least 25 feet from any foundatioa and 10 feet from any,nraQertv line �
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Person Requestmg:
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