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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # /� � � Parcel # �-S�
Zonin -_- TQwnship vv� n ��n � ti a'"''� ,, r ., ,
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Owner/Con
Location/A
Subdivision Name Lot#
S.R.#.
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SEWAGE SYSTEM SPECIFICATIONS
epair Lot Area Size of Tank "
� Mobile Home Size of Pump Tank
usiness # of Bedrooms Nitrification Line 2�� -
Max Depth Trenches
Permit Void after 60 months. Permit Void if not in compliance wi�h zoning regulations.
Permits may be voided if site is al e or
Well and Septic Layout by
Comments: "
Date Installed by Approved by
ell Permit Paid ❑ WELL SYSTEM SPECIFICATIONS
iividual Semi-Public q�ired Slab _
�blic Replacemen Air Vent
te Approved Required Well Lo
ell He roved Well T
Approved
Comments:
Date Installed by Approved by
This report is based in pa�t on information provided the homeowner or his/her representative in the appiication 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 propeRy 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 wartants 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
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PERSON COUNTY EALTH DEPARTMENT
WELL AND SEWAGE STI'E, LOCATION IMPROVEMENT PERMIT
Tax Map # ��.3 Parcel #
Zoning Township � }� � w�
/l.vr.nr/i��ntro�tnr C f� ��n �iii r f' :n �nl �1fP, /_.— 4 �
Location/
0
� <d-ov� �--�tiM `" '����e �" L.�-h�✓e �1�� ,S��e �.� S.R.# I�SZL
Subdivi
Lot#
0939
�
�
SEWAGE SYSTEM SPECIFICATIONS
Fepair +� Lot Area Size of Tank � ��
SFD Mobile Home Size of Pump Tank __7____
Business # of Bedrooms�_ Nitriiication Line
� Max Depth Trenches � �"
Permit Void after 60 months. Permit Void ' not in compliance with zo ing regulations.
Permits may be voided if site is altere nte de use c nged.
Well and Septic Layout by
Comments:
Date Installed by Approved by.
Well Permit Paid ❑ WELL SYSTEM SPECIFICATIONS
Individual 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
'I'his 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 nesponsible 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 wartants that the septic
tank system will continue to function satisfactorily in the future or that the water supply wiil remain potable. c:�amipro\permit.sam 01/95 rev.1.0
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