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. Permit requested by: . _�Dimensi ns or Proposed Scructure: I
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owner/ t: �- -
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� 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?
ome Phone #: �l� S%�I-'a�SS
usiness Phone #: .s 9y - /!%`��e�' °` � �
me and address of current owner:
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9. Water supply t}•pe:
�_ private �j . public ❑ community ❑ spring ❑
� Are any wells on adjoining property?Yes ❑ No Q
If so, identify location:
. Property Description: Lot size: �� ?Z 3�-�
. Tax Map#: . � �� � �
Parcel#: 1 Q � � k
Township: C��?�i.n� . a
i. Directions to property: State Road #& Road
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I0. Type of structurelfacility: Proposed: DExisting: Q
Type of dwelling:
House: ❑ Mobile Home: C� Business: ❑
,Type of business:
Number of Employees:
Number of bedrooms:
arbage Disposal? Yes O No �1
asement? Yes❑ Nofl If so, # of basement fixtures:
6 I�Iumber of occup ts or people to be senred� o.�_� �
CLEARI:X STAT� ALL CORNERS OF TT3E PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES•
I hereby make application to the PersOn COunty Health Departmellt for a site evaluation for the on-sice
sewage disposal system for the above described property. I agree that the contencs of [his 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 cfianges, the permit shall become invalid. I understand that before an Improvements Permit can t�
� issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have nr� _
� delivered a survey plat of the property to�the Health Dept. wi�in 60 DAYS after the date of the evaluation of
the site by the TrIealth Dept., this application shall become vo[d and all fees paid forfeited.
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Signc� Owner or Authorized Agent
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Pernni� Xssued ❑
perrnit Denied ❑
plat Observed ❑
Signature
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Date
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`� �a,�3 7 '�"�I�G1'ORS$ITE Eti!ALUA71pT� 2�t �z:i2E�' rc�r'tw' ' MlZ�3,�rt�, +�.r,�' 'A��r/���``; Y" +.�'�rr�}�xtD�1 3 ,�n'd�` 'r�c��rp,�{T� �' a°" �s.
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i. $i.iirE (s�) $ S $ $
PS PS PS PS
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2. SOII.TDCTURE(12•161N.) - S S S S
(SANDY, IAKMY. MYEY, N OTE 2:1 CLJ117 PS PS PS PS �
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J. SOILSTRVCTURE(12-)61N.) S S S S '
(Q.JIYEY SOISSI PS PS PS PS -
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d. SOILDFPi}{(iN.) S S S S
PS ' PS K PS
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6. SO]LDRARiAGElCROVNDWA7Ek S S S S
(Dl7'F�tNAL A II:TF]tNAL) PS � PS K PS
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SOILSFAfES ' • . �
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SSUITA6CE PSfROYISI0NAI�.YStl[TADIE lktRKUITA6LL
RECOMMENDATIONS/COMMENTS: -
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fi11
areas, wells, water bodies, slope pattems, etc.� C.IAMIPRUDOCSAPPSEC.S�t FWhNCEPC
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Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be main-
�ptic bank andl nitrification 1 ne SMUST BE tINSPECTF.I3�AND ZAP-
STAFF BEFORE ANY PORT ON OF THE INSTALLATIO NS C p pT
E R E D A N D P U T I N T O USE.
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Date approYed: Signe anita ian •
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Sewage 'sPo 1: Counter-
signed
By: (Owner or his representative)
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Certificaie of Comple3ion `r � '
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Date Approved: 'g rian �
(OVER)
Location of well and sewage disposal facilities sketched on back.
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now or formerly . ,
Lesler H. Dovis Sr. Es1.
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DANNY C. CL�
C�nnin�hom Twp. , Pe�son Co.
✓une /977, P/tv'//ip J. Ho/% RL
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMI'ROVEMENT 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.
Ta�c Map # /q � � Parcel # � �z
Zoning Township C�� n n�' n c� a m
Owner/Contractor 1��tn n.�► �� I� i: C�A �k D e L� -/lr�-97
Location/Address
ai) � � dL��t Pes- /��`�'� �r�, $.R.# � �_3l0
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area �_ %,�3 c� CY� Size of Tank_�X �� S�j�_
SFD � Mobile Home Size of Pump Tank N�a
Business # of Bedrooms Nitrification Line ,�' X i�S'ti nf �
Q .� ,,] ; .�j;,,v ,,.�' �,�,.,;,rla � � � Max Depth Trenches
.,
Permits may be voided if site is altered
Well and Septic Layout by
Comments:
Date
Installed by
Well Permit Paid ❑
Individual
Public
Site Approved
Well Head Appro d
Grouting Appr ed_
Comments:
Date In
blic
by.
chan
Approved by
SYSTEM SPEC +ICATIONS
eauired Slab
Air Vent
Required ell Log
Well T
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 alsa 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 remaia potable.
c:\amiprolpermit.sam O1/95 rev.l.l
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`� � AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
. DATE:���� " q� '=IMPROVEMENT PERNIIT #: �I �I3
TpX Nf�,p #: PARCEL #: / OZ •
OWNER/OWNER'SREPRESENTATIVE: DGnnJ � S��✓/�L C��t�lt
LOCATION/ADDRESS:
�.0 y(v /t�l c G� �s �.,; // f� .
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SUBDIVISION NAME: LOT #:
. SECTION OR BLOCK:
AUTHORIZATION FOR CONSTRUCTION ISSUED 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 Pernut #�73 /. 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 atterations 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:
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Permit written to allow the (,j��%��� nl � S�r��
with no chanQe or addition to the existin� se�2tic svstem,_---
Person Requesting: