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A23 141�'�'�- !�" ;,�,�.�� a��. • ;�� U r1'� z � '` � Person County Health Department � Sewa e System Improvements Permit Date:�This P it Vo'd Af��r3 Years / '��'F own�r._.:..,� , j sR� I� 7� _.. V�� ��o ►� l/ v" v , Subdivision Name: i" �� # Lot Size: ��r j/ G� v e Type of Dwelling: Water Supply: Private: j, /�• .- �, Semi Private: If not Pnvate Tax Map# Parcel # of Water Supply or Name of Supplier# Bedrooms: Garbage Dispo Basement Basement F' s INFORMA D BY -l�h� " $��jan: owner or represaitative REPAIR: REEVALUATION: Size of Septic Tank: �( Nitrification Line: _� Depth of Stone: ° ',�"as�-= Max Depth of Trenches:_ OPERATIONAL PERMIT: Remarks: �"'c� a, r • • '� j1/%j �, �/'�/,,,1� �I I . �i%,/'��i:,:"�' -= - - ' � � ' .�_ r _ IV-i�� = — !�� • �r %�i Date Well Approved: We1I should be 100 fG from any sewer system BY �ani[arian Date Sewage S stem A roved: __/ I— 3� - 9 Z i7rti�n �' o� � BY� �� �� Sallitarian t N d o � 'd � � � � 1 �� T� I�CA�TE OF COMPLETTON `#' G- �'� � Contractor. �l i cv� � � e� � ------------------------ � _ ,� Sewage System location, installation, and protection must meet state and local � regulations. Sepdc tank should be pumped out every 3 to 5 years and shall be maintained by owner in such manner as not to create a public health hazard. Septic tank and nitrification line must be inspected and approved by a member of the Person County Health DeparUnent before any portion of the installation is covered and put into use. � ` Location of sewage disposal sewage system sketched on back. _, (OVER) �t l r� ��; �� . � �� . � , �%�' . � ��.t1,,W1— � -� � =Per-son County Health -� � Well Permit Date: ��`�1Z This Permit Void After 3 Years Ovmer: .�h i 1 M a Lacation/Directions: Department � � oF� Ic� �, SR# /_322 Subdivision Name: � * �� � ��� Drilling Contractor. ,. t �' � � WF.t.T. c'c�N�'?'RUCTION Distance from Nearest Property Line Distffiice from Source of Polludon Tocal Depth; Fc Yield: GPM Stadc Water L,evel Ft. Water Bearing Zones: Dep� Ft. Ft. Ft. Casing: Depth: From to Ft Diameter: Inches TYPE: Steel Galvanized Steel [/ If Steel, does owner approve�� No WeSg}lt: Thiclrness: Height Above Groimd: Inches Drive Shce: Yes No Weze Problems Encoimtered in Settir►g the CasingT Yes No If "yes" give reason: �� Grout Type: Neat S ent Concrete Annular Space Width Inches Water in Annular Space: Ycs No � M P od: Pumped� G J.� Poiued � � De th: From to FG Materials Used: No. Bags P o r t lan d Cement Weight of 1 bag ,� lbs. � ' If mixture (sand. 8rave cuttings) - Ratio: to ID Plates: Yes No 4 x 4 slab Yes �— No De th From To Formation Descri don b c� I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT `" THIS WELL WAS CONSTRUCTED IN CORDANCE WITH REGULATIONS SET �• FORTH BY THE PERSON COUNTY PAR � - j �l �I�-9 Si of on act Date %�� anitarian's Signature Date issued Sanitarian's Signature Datc Completed Sketch well location on reverse side. A lication Date: � � �— � � Amount Paid: � Recaipt #: , �i 3 I 2— ��3 � . ������� ���.� �� � - - --- � � ����- ������,.-.�.. ��.�ma �m.�.���. APPLICATlON FOR SERVIC�S i ax Maa �• 1 ��� ParcEl #: ! '1 I �����,�`� � � � u� �� � IF THE INFORMATIOId IN TiiE APPLICATION FOR i4(d ifINPRO!lEMEPlT PERMIT iS INCORRECT F�►LSIFaED CHAiVGED, OR THE SITE IS ALTERED, Ti-�EiV THE IMPI�OVEi�lEP1T PERMIT AND �4UTHORIZ�►T10N TO CONSTa2UCT SHALL SECOME INVALID. � 1) 2) 3) � � -� Permit requested by: (Owner/agentl r pective owner): /��v �"�,Q s�• ,/l�Mo.�t� Home Phone: �g " 5� Address: K iG .J � r BusinessPhone:�/ "457�`02����c.e � ��'�t�—r . �G �7�o,s=/��� Name and address of current owner: ����.a � G � �/��a � Z. O.o � / /� ;� � Co , � �� � o �4 G ¢� , l,l'�,v�� � e �- Property Descri�tion: Lot size: ► 7 Township: �'�� �� Subdivision: /4�1C�e Lot #� Directions to the property (Incfuding road names and numbers): /�IC���c�S r�il! Qo.RJ L�%f=T o,J � .�A/� ��.�"� `�,�'i �- 4) �roposed Use and Structure Description: answer eac.� of the follow�' g questi�us: / .� a) Proposed , Existing _, Type of Structure�i� �iQGlt�C� �or4�•R�� Width:,,��_ Depth: 2-s �� �a � b) Number o Bedrooms: �_ Number of occupants or people to be $erved: c) Basement: Yes_, No � Will there be plumbing in the basement? d) 6arbage Disposal: Yes � No ?{ 5) Water Supply Type: Private _, (new _ or existing�, Public_, Community_, Spring _ Are any wells on adjoining property? Yes,�l No _ If yes, please indicate approximate location on the �site plan. 6) Does your property cantain previously icLentified jurisdictional wetlands? Yes_ No_ PLF�►SE NOTE THE FOLLOWING: ➢ A PLe4T OF THE QROPEiaTY OR SITE PLAM MUST BE SUBMIT"TED WITH THIS �►PPLICATION. ➢ PROPERTY L1NES AiND CORNERS MUST BE CLEARLY MARKED. 9 TFiE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAFCED OR FLAGGED. ➢ Ti-IE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATIOiV BY iHE'NEALTH DE�ARTtiViEAIT STAFF. 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 t the contents of this application are true and represent the maximum facilities to be placed on the property. I unders nd if the site is altered or the intended use changes, the permit shall -�� ��.�� Owner or Legal Representative � � 7 �v -., Date PCHD, rev. 06/27/02 .. ....... . ,.:��..��.� ...�.i,. i...-r .x�....[ i4 ". .� �.... �. .; .'�t:� .r.',:V ...:�. �. '�.i .�.1 t �1 � _ . .. � .i.. . .e. . e .� � . �.i ,.�t: �,. . . . . 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S R .yDRIV : : _ . _ _ _ —• __ _. — IF � . . _ ... -: , _ .. : _ ... -- - r _ �2' s l _ ; � . .. � � . , . . - _ -- , ,.. . _ , _ _ MF . : : , ,. . - , . . __ _ o , , --- . . �1 901 S89 57 05"E 270.00' TO EASEMENT _ _ - ' i � E ... - � ------ IF .' �'.'_ 2.1-:'19-49� 130.73' ._ = _. - , . . _ _ _ - - . 400. 73 . LOT`TOTAL , - . . , ,._, --_' _. . ___ � . -_ ,_. . , .. ; . - ,.; : . _.. , . _ - _:-- _. : _ _... . . - - - -• - • , :_ _ . . _ _ _ : , : ,. '. ;_ , , �_ _:_-. . . _. _ . , : . _ _..r.: _._ _.. _ . , _ .... . . , _ � : TRANSFORMER _ . . . . _ .;_ . .. _ . ,;.; -. _._ _ - , _ _ R. 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