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Im rovements Permit (Established/Recorded Lot)
rovements Pernut (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
Reinspection of Existing System (Loan Closing)
Repair/Replace existing Septic System
Permit for New Well
_ Replace Existing Well
1. Permit requested by:
�
[ome Phone #: '-1-�
,usiness Phone #: ��cl �1-� �.- � �
. Name and address of current owner:
: Lot size:
. Tax Map#:�=
Parcel#: �_
Townshin: �' L�Y
,�
se
Dimensions or Proposed Structure:
idth: �- x � o
` 8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
. Directions to property: State Road #& Road
f ames, e�C� �' �g �e il�e � ��• �
� �Yt.
. Number of occupants or people to be served:
9. Water upply ty�pe:
private public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No ❑
If so, identify location:
10. Type of structure/facility: Proposed: �Existing: ❑
Type of dwelling:
House: ❑ Mobile Home. Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �—
Garbage Disposal? Yes ❑ No ��
Basement? Yes ❑ No C�fso, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pet'SOn COunty Health Depal'tment 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 become invalid. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
Signed Owner or Authorized Agent
. .4•�--' � � .. .�... .. _
Perr.�it I�sued ❑ Signature Date
Permit Denied ❑ � a �
Pl t Ob d ❑
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1. SLOPE (95) S S S S
PS PS PS PS
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2. SOIL7EXTURE(12-36IN.) S S S
(SANDY, LOAMY, CLAYEY, NOiE 2:1 CLA� PS /,� � PS PS . PS
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3. SOII, S7RUCIIJRE (12-361N.) S S S S
(CLAYEYSOILS) S C�f� PS PS P$
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4. SOIG DEPiH QN.) S S S S
7 � / '1 PS PS PS
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S, RESTRICT[VE HORIZONS (IN.) S S S S
(�1PERVIOUS STRATA, ROCK) � P N� PS PS PS
U U U
6. SOII. DRAINAGFJGROUNDWATER S S S S
(FJCTERNAL & INTERNAL) S N, PS PS PS
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7. SOII. PERMEABILI7Y S S S
(PERCOLOATION RATE) P �� �.�( PS PS PS
U �� � �� U U U
8. AVAILABLESPACE S S S S
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9. SiTE CLASSIFICAi10N(SEE BELOW) � ' ('
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SOIL SERIES
S-SIRTABLE PS-PROVISIONALLYSUI'fABLE U-UNSUITABLE
1�COMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.) C:WMIPRO�DOCS�APPSEC.SMFINANCE.PC
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� � PERSON COUNTY HEALTH DEPARTMENT
WELL ND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT �
Tax Map # �3 Parcel # �
Zoning Township ✓ ' �
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Location/.
Subdivision Name Lot#.
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Layout I "'�j?a � r
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SEWAGE SYSTEM SPECIFICATIONS
�i �
Repair Lot Area Size of Tank /l/UL' ���' �
SFD Mobile Home Size of Pump Tank 1�
Business # of Bedrooms_� Nitrification Line 3� l�3 � _
Max Depth Trenches_��� �'
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered int n d use changed
Well and Septic Layout by
Comments:
Date3-�-
ell Permit Paid
Installed by,
WELL SYSTEM SPECIFICATIONS
by
Individual�_Semi-Public Required Slab _
Public R lacement Air Vent
Site Approved Required Well Log
Well Head Approved Well Tag
Grouting Approved
Comments:
Date � Installed by � � Approved
This report is based in part on information provided the homeowner or his/her representa[ive in the application submitted for this pertnit. The
emironmental health specialist is not responsible for false or misleading information contained in the applicatioa 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\permitsam 01/95 rev.1.0
Date: �� � � '
Owne :
Locatio irections:
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1'LRSON COUN'1'Y LNVIRONMLN'1'AL IlLAL'Cli *
WELL LOG .
� �� ��'� �
SR#
Subdivision Namc: � . � Lot #
Drilling Contractor: 1� K 1�) W L L.L1 AM 50 �1 ��
WELI. CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollution
Tota1 Dep.th: Ft. Yield: �0 GPM Static Water Level Ft.
Water Bearing'Lones: Depth t. F� Fc. Ft.
Casin : De th: From_�t�� Diameter: � Inches
g P �
TYPE: Steel � Galvanized Steel
If Steel, does owner approve: Yes No
Weight: Thickness: . �� Height Above Ground: Inches
Drive Shoe: Yes No �
Were Problems Encountered in Setting the Casing? Yes No '
I� "ycs" givc rcason:
Grout: Type: Neat Sand/Cement Concrete
Annular Space Width Inches
Water in Annular Space: Yes No
JVle.thod: Pumped_ Pressure Poured ✓ .. .
Depth: From � to � Ft.
Materials Used: No. Bags Portland Cement Weight of 1 bag_lbs,
If mixture (sand, gravel, cuttings) - Ratio: to
ID Plates: Yes ✓ No
4 x 4 slab Yes�_No
I HEREBY CERTIFY THAT THE ABOVE INFORM�ITION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON COUNTY HEALTH DEPARTMENT. �
. , .. ..
.
, � _�,�qb
Signature of Contrac _ .' Date
Nnv-26-01 03:49P
ADPIIG�Gfi I7Sts: � � ��
Amount Paid: 1l50 �
Rece�ar.rr. `2�.t3
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IC�m�,r-as-�� ,--r-..a��.7L �3C.��.u.�h►.
APPUCA710N FOR BERVICE9
P.O1
Tax Ma p #: ./ � � � -���j�
Parcet #-
IF
!} Permlt t�eque:
Home P�one:
Businass Pho�
Z} Name and ac
IN TH
3j Property De�CriptSdn: Lot sixe: /� � Towr�ship:
Dlrect��io the pro�erty (tnclu�ing road nameA and
.. . . .
� �� �.
��/.� ..._ � � �
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4) Proposed Uae and truatLra Deacripdon: answer each of e tollowlQg�estions: �_�
aj Prop� ,�Exieting _, Type of S6vcture:� .4,.�� yVidth: �pep{t�: G�
b) Number of Bedrooms: ,�� Number of occupants or peaple tfl be served: _�
c) BasemenC Yes ,_, No dI ther� be plumbing in the basemen��
d) G�t�baga Disposal: Yes � No' [�
5) Wate�' SuPP�Y TYPQ: Privete '�(new or existlng �ublic� Communftyr J Spring �
Are any wcl� on adjoining property? Yes t�No ^ If yes, pleasc indicate approximate lacaqon vn �te site plan.
8) boea the property contaln prevloualy IdantNied jurlsdictfonal vMetlandsT Yes No t/
PLFASE NOTE TNE FdLLOWING-
A A PL.qT 0� THE PROPERTY d� $ji`� pLqN MU8T BE SUBMfTTED WITH Tl�il$ APPUCATiQN,
➢ RRORERTY LlhfE$ IlNO GORN�RS MLJST 8E C�EqRLY MARKFO. �
� THE PRCP�S� LdCAT1aN OF ALL 3TAUCTURFS �+tUSt eE STAKED OR FI.AGGED.
➢ THE SITE MU9T BE RFApILY ACCES81�!_E FOR AN E�IA�UATWN BY THE HFAI.TH D�PAFZTI4AEM'.STAFF.
1 hereby m8ke application to tne Persvn County Health Departrnent fo� a sibe evaivabon fo� the on-site sewage dlsposal
system for H�e above-described prop ag�e that ttie con�n� of this appificatlon are true and repreaertt the maximum
�alides to be pl on the pro understand if the site is altereci or me intended use han es, ihe pemut shaU
become invalid. ��`�
� ��
bwner o� L I Representative. � p�
PCHO. rev. 1 pl77f0'!
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TIMOTHY JAMES SEHEN
PAMELA 0. SEHEN
CUNN(NGHAId TNP., PERSON COl1N"'. v�
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JOHN J. JENNINGS.L-3C7'[
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Tax Map #_���� Parcel # �
Existing Sewage System Report For: V Mobile Home Replacement
Addition Type:
Requester: 3,�C,.��'i
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Home Phone# ��-/ , �
Business # �1 ] 52��
Original Permit Located: Water Supply:_.�
' � �
Septic System Designed For: �dential Business Other
# Bedrooms � # Employees Other
� �
System Type: � n ank Size: Nitrification Line: i� �
Date Installed: �� �7 i� � Certified Operator Required: Y V�'
On-site wastewater disposal system shows no visual signs of rnalfunction on 0 ►'l��
Pernussion is granted to:
Environmental Health Spe
�
0
Date: - / �/� ��