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Rece�pt
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paid id�•6� ��--f �—q �
li � Date
. Permit requested by: .�= l
,��it o'g�"JOd" 7. Dimensions or Proposed Structure: I
ownedprospective owner/agent:���oi� %� �u��d� Width: �g _
. Depth: S�'�
A !i ii rP C C' _ _. ' ' _ _ .
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ome Phone #: 9/U-S�'9-/� ��
usiness Phone #: �ila �s5'.�� SoS�
. Name and address of current owner:
L`IAF�-e J'� �.L c• �s �d
� 6 3 ��'r�,S 5'�-
. Property Description: Lot size: � �
. Tax Map#: �" � 3
Parcel#: .�
Township: U nf � i tv4 �i�n � owNs{1,�
�. Directions to property: State Road #& Road
lames,�tc.
S'O I N "r.'o �9�r� s7 -��re. �/l �ti�
/A,!% �,-1 'i r, i»c.E�Pccs .� // % /P d
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I�Iumber of occupants or people to be served:
8. What type (if any, additions, expansions, or
replacement is anticipated to the s[ructure or facili[y
that [his sewage disposal system is intended to serve?
No � e _
9. Water s ply t}'pe:
private . public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No [�
�If so, identify location:
1. Type of structurelfacility: Proposed: �Existing: Q
Type of dwelling:
House: ❑ Mobile Home: Business: ❑
Type of business: N��
Number of Employees: �
Number of bedrooms: S
IGarbage Disposal? Yes � No �
Basement? Yes ❑ Noi�so, # of basement fixtures:
CLEARI:Y STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRU
C�'URES• .
I hereby make application to the Pet'Son COunty �ealth Depaxtment for a site evaluation for the on-site
sewage disposal system for the above described property. I agree that the contents of [his application are true
and represent the maximum facilities [o 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 bc:
issued, I must present a survey plat of the property to the Healch Dept. I understand that in the event I have not
delivered a survey plat of the propercy to-the Health Dept. wi�in 60 DAYS after the date of the evaluation of
the site by the I-iealth Dept., this application shall become vo[t� and all fees paid forfeited.
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Signc� O er or Authori ed Agent
permit Issued ❑
Permit. Denied ❑
Plat Observed ❑
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5i �1.��.�..�rah� <. .:... ..,>., .. ...-...;-.� ,�xa^k'i�.,ro'i i?,, `��,afr.r� iski.sl3i€'F"�L!::..�u�"l..... �..a � as �:V�n,»sr�l 1VX./a.f`!` � �tk�:eg...,�1^i ti!a��. ..a�.6 �i`i�
1. S1APE (A) S S S
. PS O (�'�j PS PS PS
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2. SOII.7FX7URE(12•)61N.) • S �% S S S
(SANDY. (AAMY. MYEY. NOTE 2:1 Ml� . � J�'__ PS , PS PS .
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3. SOfLS17tUC7URE(11•J61N.) S S S S '
(QAYEY SOR.S) S� PS PS PS -
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3. SOILD&'T'i (W.) S ��. � S S S
� PS PS PS
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3. RESTRICTIVEHORRANS(iN.) S S S • S�
(ASPERYIOUS ST7iATA, ROCK) �� PS PS PS
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6. SOA.DRARIAGEICROUNDWATER S S S
(FXfFRNALA WTFANAI.) /�JY� PS PS PS
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�. SOILFf7tMFJ18Il7TY � /�y� S S S
(PFRCOtAJ1TIONRA'[� . 3 /*f'� PS PS PS
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E. AVAIIJIBLESPACE S S S S.
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S-SVITAIILE pSTR0Y1SI0NALLYSULTACLE tl-VNSUftAIIIZ
RECOMMENDATIONS/COMMENTS: - —
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, properly lines, roads, streams, gullies, wet areas, �'ill
areas, wells, water bodies, slope patterns, etc.� C:MMtPRUDOCSV�PPSEC.Sr1 FINANCEPC
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B 1739
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 # �.3 Parcel # � �%
Zoning Township �V nn �'n� !, q�--.
Owner/Contractor
Location/Address
Subdivision Name
Lot#
ate �- //- 9'"%
s G4, dz�
s.R.# l3� 3
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area .� q�es Size of Tank ��� rc y�
SFD - Mobile Home_� Size of Pump Tank �1�
Business # of Bedrooms� Nitrification Line pU X�
Max Depth Trenches � 6 `�
Permits may be voided if site is
Well and Septic Layout by
Comments:
u
Date � Installed by ` Approved by
. �
Weil Permit Paid ❑ WELL SYSTEM SPECIFICATIONS
Site Approved.
Well Head Ap
� Grouting A r
Comments:
Date
ni-Public.
lacement
Installed by.
�quired Slab
ir Ven
e ' ed Well Log _
ell Tag
/
pproved by.
This 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
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 Cou�ty 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: (o - �% 9 �% �'ROVEMENT PERMIT #: � � `7.3
TAX MAP #: � PARCEL #: /
OWNER/OWNER'S REPRESENTATIVE: ���{ i h{ /�� � v v�s��' a�
LOCATION/ADDRESS:
SUBDIVISION NAME:
0
. SECTION OR BLOCK:
. AUTHORIZATION FOR CONST$�CTION ISSUED BY:
AUTHORIZATION CONDITIONS
�
LOT #:
1. The Wastewater system construction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Pernut #� The
construction and installation must also meet all applicable rules and laws.
2. No portion of the Wastewater system shalt be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any alterations in site or soil conditions (including structure locations) 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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1) Ponnk raquoetod by: �o���P��►. a,�.,�: Fr�e�� ��s
Hane Phone: 5�-l'1-S 53�? � Address• .'�G "� b i�c �-v�.�� O�ca
eus;ness Phone: s� �-���Q Ro k��� N� z�c � 3
� Namo and ad�+ess of cument arunsr- :�'-�"�-- ���o.0 r i�J��S
�-v�y � �:���,s Ctiur�. R�I
�a.an� n ra 4 N L 2'1 �l1"t
3) Property OesMptbn: Lot size: o� Ac.r.ESTovmship: s• ;� Subdhrisbn: lot#
DlrecEions to the property (t�duding road names and numbers):
4) proposad Use and Struciurs D�on: answrer each of the fdlowh�p questio�s:
a) Praposed � E�dsdn9 _,'Type af Shuchue: I��w.���� �-�.,.a YVidth:� Deptt�: ��o _
b) Numbec at Bedrooms: � Number of occuparrts ar peapte to be served: ?.
c) B� Yea_, No�, 1IV� the� be plumbing h the basement?
d) �arbage Disposal: Yes _, Na �
� Watsr 3upply 7ype: Prlvate .� (new _ ar eods�ng,�}. Public,_, CommunityJ SQdng _
Are arry w�elb on adJ��9 P�'�Y� Yes tVa _ 1f Yes. Please it�dl�e aPprwdmaDe location on the
•siie plett�. .
6� Ooes your prnPoK71 ��� P��ualy identifiad jurlsdictbnal wetlarsds7 Yes No�,.
• t.l- �1--- •�.1
➢ A PLAT Qf THE PROPERTY OR SiTE PLAN MUST BE SUBNfRED WITH THIS APPLICATWN.
� PROPER7Y LINES AND CORI�lEIZS MU9T BE CLEa1RL.Y MAR1�D: �.
D THE PROPOSED LOCATI�I OF ALL 8Tt�JC711RES YIJST BE ST�1itED OR Fi.AGG�D.
➢ THE 91TE NU9T BE RFADiLY ACCESSIBI,E FOR AN EYALUATION BY THE HEALTH DEPARTNENT
STAFF. �
I hereby make a� to tl�e Person Cautty Heeltfi Depattrnerd for a s�e evaJuatian far the on-site sewage dispo6al
sysiern for ihe above�escxibed properfy. I ag�+ee Urat ihe coc�ts of dus applk� �e true and represent ihe maximum
tacilitles to be Qlaced on the ptopeRy. i tsndecstand if the s�e is �tered or the h�ended use dtangea, ttre permit st�atl
become I�vaNd.
S-1Z-�-I
owner a R�a��t�atwe oate
�p. ,e,�. aerz��ro2
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= �t_ ��+�[ �"���
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Taa �ap #� Parcx� # ZS�_ .
�is ' S �rt �a� � blob� �om+� Re�Iac�t .
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g$�,� �lct'� �I;�'R3� a �`�Y��`'� � Eome Ph�ae�# �7`S��i
�7'� � � �A�-cPScGS C� = Bnsi�s #
� ��r� � � 23 �� �
o� P���a: ��_ ��« s��: ���� l,c�e �(
Septic Sp9tem I)esigt�e� For. �'��",�*a� Basaa,esa CC�azes .
# Bedtaams � # Emp�oye�s �r . �
s�Typ�: C���'�i ��.s�� 1�D a i���� ����_3 <
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. �� rr��:. � — �2 c ^R'7 - c��. o� �: � .
((�a-eite wastew�ater �iis�eal spstam show� sto v�suai signs of m�ifiiact�ioa on S�� `�
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