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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
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 # /4 � � Parcel # � � �
Zoning Township �a{- �; J e�f'
Owner/Contractor (� o(10.. � �i �(�. r-� n,� Date Q-S- 4' `1
Location/Address �- �s��l�.o,� e�a.� �o�G G�o C2..�(�ro,r,.
� m', � P S o n (Z : c� i� -1— S.R.#
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area o'�`"j, $� Size of Tank / d�t�
SFD 1� � Mobile Home Size of Pump Tank N//�-
Business #ofBedrooms '3 NitrificationLine �j �� �l3 /
Max Depth Trenches c,7 t/ �'
Permits may be voided if site ' altered or
Well and Septic Layout by
Comments: � �Q�v,/� � _- �
Date ! 1 / (a / 9R Installed
changed.
Approved
Well Permit Paid WELL�SYSTEM SPECIFICATIONS
Individual ✓ Semi-Public Required Slab -✓ �a 3
Public Replacement Air Vent � Q��OC
Site Approved ✓ I�I�I9a Required Wel� Log r/ I
Well Head Approved l/�) ?R� �- , Well Tag �� �L
Grouting Approved ✓ Ia�3�q�
Comments:
�.__,. _ �,t..._ _ _.. ...�.,--- --- r--- - --- ---------- �-- - - -
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
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: Q—�5— '7 � IMPROVEMENT PERMIT #: � I 88
TAX MAP #: _�- �I ,� PARCEL #: cQCj
OWNER/OWNER'S REPRESENTATIVE: ��n GLI Q� ��,�,�'-{-��
LOCATION/ADDRESS:
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SUBDIVISION I�IAME:
LOT #:
SECTION ORBLOCK:
AUTHORIZATION FOR CONSTRUCTION ISSUED BY:
AUTHORIZATION CONDITIONS
1. The Wastewater system canstruction and installation must meet aII of the conditions of the
attached site plan and specifications as set forth in Improvements Pernut #��. The
construction and instalIation must also meet alI applicable rules and laws.
2. No po�tion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any atterations in site or soil conditions (inciuding stnicture Iocations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authorization and associated pernuts.
4. Conditions:
Person Requesting:
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Mrs. Alien S. Horn
Tnomos E. a no��r c. L«,q
D.B. 190-515
Thomcs E. 8 Oolly C. Lonq �
and
Joe 8 Emtstine C. Lonq p�'
0. B. 154-569 �
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Thortws E. 6 Ooily C. Lonq
0. B. t90- 515
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0. e. t90- 313
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REFERENCES . � . .
• P�RSON COUNTY ENVIRONMENTAL H�ALTH
WELL LOG
Date: �! � �� .., ?� . SR# - .
Owne�: �� � �
Location/Directions: .
Subdivision Namc: L�t �
Drilling Contractor:
►, ;� �„-� W�l LU la�M SCl�tJ T.N � -
WELL CONSTRt�C'1'�ON
Distance from Nearest Properry Line _ Distance from Source of
Pollution GPM Static V►/ater Level Ft.
Total.Dep.th: F� Yield: .
Water Bearing Zones: Depth rt..,_._.Ft. - F�' /�t �ches
Casing: Depth: From�_to � Ft. Diameter:
• Galvanized Steel '�
TYPE: Steel �
If Steel, does owner approve: Y�s N0- Inches
Weight:_'1'����5� • ' Height Above Ground:_
Drive Shoe: Yes No . �
Were Problems Encountered in Setting the Casing? Yes �__ No_____.
;. "ycs" givc rc:ison: .
Grout: Type: Neat _ SandjCement Concrete
Annular.Space Width 1�.��ches
Water in An�►ular Space: Yes _ No_
Method: Pumped � Pressure_ Poured �=
Depth: From --_ � to 20 Ft.
Materials Us«l: No. Bags Portland Cement______ Weight of 1 bag_.lbs.
If mixture (sand, gravel; cuttings) - Ratio: to � .
ID T'latcs: Ycs � — No__ .. �
4 x 4 slab Yes ✓ No _ ,,.
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH REGULATIONS SET
FOR1'H BY•THE PERSON COUNTY HEALTH DEPARTMENT.
�'� , ' � -�'t
Signarirc of Contract � atc
A 'lir.ation Date: �- 2�-
Amount Paid: - D
Rec�ipt#: n
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APP�lCAT10N FOR SERVICES
Tax Maa #:
Parc�l #: �4 / / J� �
IF THE INFORMATION IN THE APPLlCAT10N FOR AN IMPROVEMEiVT PERMIT IS INCORRECT. FALSIFiED,
CHANGED OR THE S1TE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZl�►TION TO
CONSTRUCT SHALL BECOME INVALID. -
1) Permit requested b:(Owner/agent/prospective owner): 1� / � �G ���L�Cv U�U��,C)
Home Phone: j . � � Address: � ✓
, Z �
Bus9ness Phone: - �
2) Narne and address of current owner. ��i� -c_. 2��`�3
3) Properly Description: Lot size�'�� Township: ���/��t�ivision: r�� Lot #��'
Directi�ns to the prop�rty (!r. 'urlin nam�s a•numbers): �'�
N
4) Proposed Use and Structure Description: answer each of the following questions: �y f �r /
a) Proposed _, Existing Type of Structure: Width: Depth:
b) Number of Bedrooms: � Number of occupants or people to be served: �- �
c) Basement: Yes . No ��II there be plumbing in the basement?
d) �arbage Disposal: Yes . No _
5) Water Supply Type: Private �(new _ or existing � Public� Community_, Spring ��pl /
Are any wells on adjoining property? Yes_ No �tf yes, piease indicate approximate location on the
'site plan.
6� Does your propeity cantain previousiy identified jurisdictionai wetiands? Yes_ No��"
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPEi�TY OR SITE PLAN MUST BE SUBMITTEU WITH THIS APPLlCATION.
➢ PROPERTY LlNES AND CORNERS MUST BE CLEARLY MARKED.. ,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAI�D OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE NEALTH DEPARTMENT
STAFF.
I hereby make appiication to the Person Caunty 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
became invaiid. � a
r
Owner or Legal Representative
����
Date
PCtiD, rev. 06127/02
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Tax Map # �y � Pazcel # ��
Fxisting Sewage Spstem Report For. �C Mob�e Home Replacement
- Addition Type:
Requester:
�C�,c,<i� ��lc ��^ Home Phone# � `� ' a�� �
� 1 cX-i t���� '� Business #
1 ���4�5�, ��- `�?��$3 .
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fZc � 1��� c>-, i 12 � 1 a
,
Onginal Permit Located � 1�_ � Water Supply: �''�uC'�.�-�-
Septic Sqstem Designed For. � Iteaidential Business Other
# Bedtooms � _ # Employees Other
Syetem Type: i� n.� � X Taak S3ze: IL� (� Nittificadon Line: �-� .k 3�
Date Installed: �1 �� Lo I 9 g' Certified Operdtor Required: (1Q �
On-site wastewatet disposal systein ahowa no visual aigna of malfunction on 7- a 3-U�I
Permission is granted to: �^' . �' 'i -� '►��aCsz a, 1 �-1 x ? � �,o.•-.� �. � s'+-e .
Comments: ��.:Y,�-��, cSL.\ �-e�b�-c�. � �t- c!�,`:� c�szr
� �-�. .. �si �e
Environmental. Health Specialist Date: 7- c13-v��
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Tag Ma.p # � � ► Parcel # 7c�
Section/Lot# �
7- �3—��!
,. : : Date . ; .
Systesn components repr�sent a�imximate�contours only. The co�ractor must_ flag the syster�z jirior to.,
begiraiing the znstaAaiion to insure that pr+opergrcde is mcrintarned �
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