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provements Permit. (EstablishedlRecorded Lot) _ Reinspection of Existing System ( an Closing)
mt�ovements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) _ Permit for New Well
Improvements Permit (Addition) _ Replace Existing Well
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E: 1 i `s3' 3"3� hS ��'`b� eE.'�yx �'•'� g� r>�,t san .rw � xi s'� :J' '{��es.:',� i�' �,�".�.r z h �ji' S'"�'�' ..
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Bacteria _ Chemical Petroleum _. Pesticide _ Lead
Permit requested by: .
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,
7. Dimensions or Proposed Structure:
Width: ��
n,.�.�.. '"'i!1
J � �- L.,y�... �, —
-��3 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?
ne Phone #: ,�� "`� � �vb--
iness Phone #: �—
Name and address of,
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;r; �7 i I� 9. Water su }�e:
�.�'ile private . public ❑ community ❑ spring ❑
, , Are any wells on adjoining property?Yes ❑ No Q
-�,�j � If so, identify location:
u
Tax Map#: �� � � P �
Parcel#: , � i - q , ��
�Township: l�
Directions to property: State Road #& Road
imes; tc. S�
13 I a `` eY��'c,11 S e� �-� �-
:�-� � 2 2 2-�-n S i2-f�- i 31 S? t�
S 12 � � 1 'L
10. Type of structurelfacility: Proposed: OExisting: Q I
Type of dwelling: ��
� House: ❑ Mobile Home: L�Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: .��
Garbage Disposal? Yes ❑ N �
Basement? Yes❑ No � f so, # of basement fxtures:
LNumber of occupants or people to be served: �_� �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PersOn COunty Health Department for a site evaluation for the on-site
sewage disposal system for ttie 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 pla[ 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.
¢ , , / . .
z Signc� Owner or Authorized Agent
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SSNTAOLE YStR0VIS10NALLY SURA6LE U•UNSU(TABLE i
RECOMMENDAT ONS/COMMEINTS: vo��5 on (.ai- a.re Pr �s; �' �
n�i`� CQh � �S�SrtA+°�` DnG� `�'� 'F+on � 5 y�� il►e� a.oi ^` _
SIT CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, we[ areas, ii] �
areas, wells, water bodies, slope pattems, etc.) C:MMIPR SAPPSEC.SM�N ��
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B 1249
' PERS�N CC��JIrTTY HEALTH DEPARTMEN'T. .
�,'+ `�` WELL ANT SEWAGE SITE, LOCATIC�N Il�4'ROVEMENT PERMIT -..�......- _
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' l�ot for waste water system construction. No permit(s) for Construction Location ar
�o�oca�io^ Activity shali be issued until Authorization for waste water system construction
has been issued.
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Tax Map # � 2 � Parcel #_� �i� �
Zoning Township __ _ n �" r� �i ,�-t
Owner/Contractor i' n'� ,r, �i ��e % pn Da � D'.2 �— �% �
Location/Address_ � � �r � 22 � � �,� -�= i ? / � -�, 5��- I 3/z
Subdivision T-,a:m�
Lot#
S.R.#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area /, (, Gt (.ye Size of Tank��Q ) � � r
SFD Mobile Home 1/ Size of Pump Tank NI �•�-
Business # of Bedrooms �-3 Nitrification Line�� a' X 3`-�,—
Max Depth Trenches ..? j� "
Permits may be voided if site is altered
Well and Septic Layout by
Comments:
use�changed.
�� a�l�u� r+�s
Date
Comments:
Date / _� Installed by.
l'GtiP,(�i�Q. Approved by
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permit. 'I'he environmental
health specialist is not responsible for false or misleading information
contained in the application. The environmental health specialist is aiso 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 rem�in potable.
c:\amipro\permit.sam Ol/95 rev.l.l
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: - l�' C l�
IMPROVEMENT PERNIIT #: I-2 �
TAX MAP #: PARCEL #: _
OWNER/OWNER'S REPRESENTATIVE
LOCATION/ADDRESS:
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l 1 YYI���/ S�� e�
Si�� 133� ��,� �3z2 ��r� i3�� � s�/3iZ
SUBDIVISION NAME:
SECTION OR BLOCK:
LOT #:
AUTHORIZATION FOR CONSTRUCTION I5SUED BY:
AUTHORIZATION CONDITIONS
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 Permit #���,? �i. The
construction and installation must also meet all applicable rules and laws.
2. No portion of the Wastewater system shall 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 permits.
4. Conditions:
Person Requesting:
cs a deCenaination eo the
ul ability as m Q�wiaioRs �
above. .
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Jan-09-97 10:16A Barnett8 Well Co. 910 599 0015
� � PERSON COUNTY ENVIROt�TMERTAL HEALTA
, . , .
. � Owner.+G �p� '
L,acation/D'u-ections:
Subdivision Name: _
Drilling Cbnoractor: _
WELL LOG
P.OZ
SR# '�
Lot #
Discance from Nearest Property Line_ !o `f _ Distance from Source of
Pollution /�` � '
Total.Dep�h: !� Ft. Yield:�, GPNi S[atic Wa[er Level d___ -?�__�_��,
Vi�ater Bearing Zones: Depih Ft F� F�. F�
Casing_ Iaepth: From ��,_ro �'� Ft. 13iameter: Inches
�'YPE: Steel - GalvaniZed Steel �-
If St�ei, does awner agpro�e: �� I�io
Weight:- 'Tiuckness- /� I�eight'Above Ground• /S' inehes
Drive Shoe: Yes,� ,�/_ No ,
Were Probiems Encountered in Setting tiie Casing? 'Yes No ---
If "yes" gi�c r�son:
Grout: Tyge: Neat SandJCement Concrete
Annu�ar Space Width Inches
Watea- in Annt�lar Space: Yes No
_ . Method: Pumpe� - �Pressure Aoured -� ._ . .
Degth: Frbm � :o c� Ft.
Materials i7sed: No. $ags Portland Cement V�Teight of .1 ba�^}bs.
If mixtuie (sand, gravel; cnitings) -�atia: to
�3� Plates: Yes �/' No �`
4 x 4 siab Yes ✓ No
I HEREBY CER`I�F� THAT'i'HE AB4VE 11VFORMATIQN IS C�RRECT AND THAT
THTS WELL WAS CaN5'i'Rt3CTED �t ACCQRUANCE WITH REGULATIONS SET
FaRTH i3�' T�-�E F'ERSQ�1 C�iTi•li'y HEAL H DEPARTMENT.
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Signaturc oCContractor I�at�
Nov-26-01 03:49P
Apalicatia� Dats: �'0 '6 �
Amount Pai.d: � �
Recalpt#: �
Tax Map #: � i ��
Parce!'#: � � O
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APPLJCAT1dN FOR SERIACE9
P.O1
NE INFORI4AAT10N IN THE APRLICATiON FOR AN lMPROVEl�/ENT PERliAIT 13 INCOkRECT FALSIFIED.
1j Permlt requeabod b�yt•�, (Ownerlaqontlproapectivo ovmer): �L
HomePhone: �7%��:��� Addf�SS: d D� � .
Businass Phona: �� 7-�3-�2.� C►., j�
2} Namo and addreaa oi currefit ov�vne� �ip�� ,� A/
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.5.� �ot�
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3} Prop�lty D�C�iptlOn: LOt 8ize: • d�OWftBhip: u rvtsbn: Lot #:
Dlrections to fhe proprlty (tncluding,road names and numbers): e5-7 NLJ 77� // �Tu�it% ,�.z� � 7--
%i��il> . ��.�= C� r� 7-' �l ,� ,c��.C. �'"Gy �d d .G /�l�if�
� �-�` T— �'ry-.� , � � a �,� .,�..z-.c.� s -�T.E- �
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o fi�`A��S G 2.��
4) Proposed Uae and Structvre
a) Proposed ,� , -Exiering J
b) Number of 8edrooms: �
c) Basement Yes _, No �
d) Ga�'bago Disposal: Yes ,�
No
_ � LcJ�O.E" -�-.s'�—Y,�' D �sC��T-
!pdon: answer each of the lollowing questions:
of Sbvcture: Do�,O�C.F" 4�D,�" Wldth:� �Depth: �
�er of vcaupants or peaple tfl be served: v'""
�e�..plumbir�g in the basement�
�
5) Water �uppty Typa: Private �/(new ^ or ex�st
Are any wciks on adjoining property? Yes _
r
1g , PuWic� Communfty ,_, Spring �
Nv ^ If yes, please indicate approximate locadon on the sfte plan.
9) boea the property contaln prevloualy Identifted jurladlcxE�al virotlands? Yes No �/
PLFASE N�TE THE FOLLOWING:
Q A PIAT QF THE PR�PERTY QEZ $('i'� pLAN MU8T RE SUBMRTED VyfTH TH�$ qPPUCATIQN.
� RRORERTY LIIVEg AND GORN�RB M115T BE GLEARLY MARK�O.
➢ THE PROPaSED L�CATION OF ALL 3TAUCTURE31rAU5t HE STAKED OR FLAGGEp.
➢ THE SCTE MU9T BE FiF�►p1LY ACCES816LE FOR AN EVAt,UATFON BY THE HFA�TH D�PAFrTMEM .STAFF.
1 herehy m8ke applicatiott to the Person County Heakh Departrnent fo� a sibe evaluation fo� the on-site sewage dlspasal
system for tl�e abvve-described property. i agr�e that the con�en� of this appffcatlon ar� tnte and represertt the maximum
faalides !o be pl on e pr�pe . nderst�nd if the site is altered or me intended use n s, the pemvt sha►I
become invaiid.
bwner or L Represc�tative. � ��
e
PCHD. rev. 1 Un 7f0'!
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Tax Map # f la3 Parcel # I�
Existing Sewage System Report For: V Mobile Home Replacement
Addition Type:
Requester: �t n C- �, J c�� n � O �'� Home Phone#
�� 'T'�C rr c! J �j�,p� �� o�td Business #
S�cmura iJ o27 3
Locarion• 7 N K. Cunn i n� G rn I�d • Tt rr-� II SG�ic�� I�(,
�jc.a� L�cc'� ForK �Omc O� � ��x � ���
Original Permit I.ocated: / t"S Water Supply: �r� Ja�- W<<�
Septic System Designed For: V Residential Business Other
# Bedrooms � # Employees Other
�X �
System Type:��vcn�ionu � Tank Size: ��7 Nitrification Line: � �
Date Installed: I—, - I� Certified Operator Required: N�
On-site wastewater disposal system shows no visual signs of malfunction on � '��
Permission is granted
in�ilc. (..� icl � t,.�►-�. a o�`�' X io(o ` J7nu.t�l� l�� d�
� E��t �
Comments: I�i�ca h�m� F'ront�'S{.owld b�c plac� d in 5li �nz arca as
Fron�t c,clg�, OF Si�n�i(c W�dc, `�.�5 W11( G.��01.� 10� Ti7 S�P�� SYSt�m
� �'1� �O �Xi'S-�In� lJt / I• `� )RLK T�r�uq� gl- ,Bcdro�m CO(.t,/1�'
t,� i I I be pc r Farm �d 6t Fo �c
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Environmental Health Specialist
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