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PERSON CO TY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
Tax Map # 2� Parcel # � � - �� 32 ' �ke _,
;.�--� -a � �
Zoning Township.� � ���� �ti�,�„�
Owner/Contractor Date� r-2_���
Location/Address ' � '
S.R.# / � � �
Subdivision Name
Lot#
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits ma be voided if site is altered ' tended use c an ed.
Weli and S ptic Layout l�y /�n �� ,�r���,;� ,,
Comments:
Date_�� Installed by��T I�1 � j�{ Approved by.
This report is based in part on information provided the homeowner or }u`s/her representative in the application subautted for this pemut The
environmental health specialist is not responsible for false or misleading information contained in the application The environtnetrtal heaith 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 Coutrty nor ihe environmental health specialist wazrants that the septic tank system will
continue to function satisfadorily in the future or that the water supply will remain potable.• c:�amipro�pecnritsam Ol/95 rev.1.0