A24A 24aaa�s �i: � � �� .�e� �`�'�a �'� .
No. of persons to be served Bedrooms 1; 2 3; '4,
3'
Additional appliances to be used: Disposal, -dishwasher,...wasliing;
. �----r
machine .-
Recommended• Septic .tanl �
d � �
Nitrification line: �� �: . � . �/1 ' '� �,�T� :
Above recommendation based-on information-received-and-�obse�ved �
soil- condition. Septic tank and nitrification line must �bc inspected and
approved by-a member'of the Distzicf Health D�epartment'sfaif"before
any portion of the installation is covered. _
Date Approved: .. i'�]
�,.._.��9�1'
� Signed •' ,�
Sanitarian � : . �,�
By• , . .
O. David Garvin, �M:D.� M.i'.$.
District Health Officer
Countersigned
(Over) . .
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Improvements Permit. (EstablishedJRecorded Lot) _ Reinspection of Existing System (Loan Closing)
Impxovements Permit (Unrecorded Lot) ,_ Repair/Re�place existing Septic System
Imarovements Permit (Mobile Home Replace) ._ Permit for New Well
Permit (Addition)
_ Replace Existing Well
��..�>.,�« x �.�.�:,. �r:::�x r��,�..: _ �,...�..,.�.T� _... _ .....__ _
Bacteria Chem�cal Petroleum Pesticide _ �a
1. Permit requested by: . � 7. Dimensions or Proposed Structure:
o Width: 27'- 3" C�U � A��i �
owner/prospective owner/agent: Fay _�„( ,�,LM�N C�+�3„ , � �'� ��
Address: . 7a.9 ctt �+ P�� :!-1 r �� `r��h-� Depth: 1�' _ o" I� v�
QuRt�.��-vN '� c�-� �-' S g, What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
ome Phone #: . �
� " ��9-7�/57 .,�..
usiness Phone #: g o.- � �' �� �
Name and addre�s of current owner: �_
,,nli�u�rnn E-. � �R219ARh �'• S�tF ,
2G39 LiMSTEN-s� �� / %I.7 ��•; f �:.
e.
. Lot size:
,��,�<,,,,
v
_ 9. Water supply type:
_ private � . public ❑ community ❑ spring ❑
� Are any wells on adjoining property?Yes ❑ No [�.
_ If so, identify location:
Tax Map#: f-t � � /7` ,
Parcel#: � �i`� • �'�'�� �i �
Township: ��-w1-;,�,._%��u�-�—�-L---
�
Directions to property: State Road #& Road
trwy s�N- �� �N� -�,�,� 1��E� c�u��� �� -�
ou'rv �iNt1��/t��cN ESr.�'J-�s 2cl — �f'iGk�" vN7l�
Mn-s.c.,�12J s Lc%t y � L ���'r nT +� / 05�
10. Type of structurelfacility: Proposed: �Existing: Q I
Type of dwelling:
House: � Mobile Home: C7 Business: ❑
Type of business:
,Number of Employees:
Number of bedrooms: 3
Garbage Disposal? Yes ❑ No �
Basement? Yes ❑ No� If so, # of basement fixtures:
6 Number of occupants or people to be served: 2- � �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pet'sOn COunty Health Department 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 [he proper[y 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 �Signcc� Owner or Autho'rized Agent
�
. ,¢,�-c .
Permit Issued ❑ Signature Date
Permit Denied ❑
Plat Observed ❑ ` . �-•
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, �11
areas, wells, water bodies, slope pattems� e�C.� C:MM[PRO�DOCS�APPSEC.SM FINANCEPC
B 1230
PERSON COUNTY HEALTH DEPAR'�MENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
T- . .
1Vot 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 # ���� Parcel # � �
Zoning Townshi C 1/ 1-� r�i ��c, ti r-i
Owner/Contractor �' J,'�� 5� /� Dat C% /�
Location/Address �-�7 !�1 -+.� �f � �,, S'R-(� j � I �F �ti e�� ,lz�
/.� � o� Pi nrc �r•�J, ��r� h.� �Jw�� k _M�,llaY� 1+1C� . S. .# / � �
Name
LOt1t r � �
SEWAGE SYSTEM SPECIFICATION5
� Repair Lot Area
SFD Mobile Home
Business # of Bedrooms
,
�
�,.,n ��.,� �.d� � �
�
v Permits may be voided if site is altered
� Well and Septic Layout by
a Comments:
Date .. Installed by
Individual � Semi-Public
� Public Replacement
Site Ap oved
We ead Approved
� outing Approve
� Comments: �
Size of Tank ���5•ii �
Size of Pump Tank i.� �'�� `
Nitrification Line �x: s�, • '
Max Depth Trenches
use changed.
�
• v
Well Permit Paid ❑ ELL SYSTEM SPECIFICATIONS
Date
Installed by
Slab
Air Vent
Re ' ed Well Log
ell Tag
Approved 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
co�tained 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 applicatioo. 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\permit.sam O1/95 rev.l.l
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