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Permit (Est�blished/Recorded Lot) Reinspection of Existing System (Loan Closing)
Improvements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) _ Permit for New Well
_ Improvements Permit (Addition) I Replace Existing Well �
Permit requested by:
t��,�4 ospective owner/agent:.
d�e I C� ✓e!�
_ .aF. '`��84 ��'%�VD i
� 7. Dimensions or Proposed Structure:
7E'_ �� 1'c ss Width: �
�nz Depth: � '��0'�
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me Phone #: S - ��.-�'/�
siness Phone #: iU o
Name and address of current
� � -�i , /
Descrintion: Lot size:
Tax Map#:
Parcel#: _
Township:.
Directions to property: State Road #&
ames, etc. � n � �
�- n�. _ i�^> f'i � L
Number of occupants or
re
to be served: �_
8. What type (if any, additi�s,:expansions, or
replacement is anticipate� to the structure or facility
that this sewage disposal system is intended to serve?
��Water su ly ty�pe:
�`livate public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No ❑
If so, identify location:
10. Type of structure/facility: Proposed: �xisting: ❑
Type of dwelling: /, �tJ
House: ❑ Mobile Home: �Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: ___�__
Garbage Disposal? Yes ❑ No CC1�
Basement? Yes ❑ No C�f so, # of basement fixtures:
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 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.
W
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Signed Owner or Authorized Agent
�
Permit Issued ❑ Signature Date
Permit Denied ❑ .
Plat Observed ❑ � , �i_ � _�-� p� /3 �
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2. SOII. TFXTURE (12-36 IN.)
(SANDY. LOAMY. CLAYEY. N07E 2:1 CLAY)
3. SOIL, S7RUCilJRE (12•36IN.)
(CLAYEY SOiLS)
4. SOIL DEPTN (IN.)
RESTRICiIVE HORIZONS (IN.)
1PERViOUS STRATA. ROCK)
SOIL DRAINAG&GROUNDWA7ER
KTERNAL & INTERNAL)
SOQ, PERMEAHIUTY
3RCOLOA770N RA7�
AVAiLABLE SPACE
SiIE CLASSIFlCA710N(SEE BELOW)
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RECOMMENDATIONS/COMMENTS:
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SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, We��S, water bodies, slope patterns, etc.� C:WNIPRO�DOCSWPPSEC.SMF[NANCE.PC
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DCRALDCIC G SQ101f0�(
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMI'I'
�.- Tax Map # � .2 5 Parcel # �
4 , 7oning Township ' �.�
Owner/Contractor � oe � � c'�.S � e��
Location/Address C tl �k �� Z'� -i„ S�� L'� ��7 ,/o-� o� l e�'-f- j �
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Subdivision
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Layout
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S.R.#
Lot��� _ _ � � .
As Installed -
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SEWAGE SYSTEM SPECIFICATIONS
/ �1
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Repair Lot Area /, b G�Cde Size of Tank n
SFD Mobile Home�� Size of Pump Tank n��
Business # of Bedrooms�_ Nitrification Line �� rX 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 or ' ten� ed use c nged.
Well and Septic Layout by ��l/n.✓i � f�r S.
IWell Permit Paid L� WELL SYSTEM SPECIFICATIONS I
ic
ell Head
Comments:
-Public Required Slab _
cement Air Vent
_ Required Well Log
Well Tag
Date __ � Installed by �-�� �l �� S Approved b}r �� "�/� � �'�`1:��'.�
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 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 environmentai 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.1.0
I'I•;It:>ON COUN'I'1' I•:NV.I:Ii0NM1.:N'1'AI.., III:AL'fIl
lJl•:I,L. LOC
",�, � -, Dale:�-���'
Owner: _ � 10 � _��S
_------- --- -
. ___ --__ ---- -- --
ocat�on/Dixections_ —
SR�� _�3,�,Z,_
. --- _
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�;:L:.':visiori N�u���;: b�, J/� f+-�.� �_A'�/�- _---- _ • _ .
�5�.,� Lo � ��
Drilling Conu-actc�r: ����,, , rA i�/ _�
� wr1_.t, CON�STRUCrI N
Dista��ce fi-om Neru-�s� Prop�:rty Li,u���� �„s llist:incc .from Source of �
Pollution o � �,,��, . � .
Tocal Dep.th: �— �Ft. :� ����:_�__ �;pM Scatic Water Lcve1 �
Water Bearin Lones: Dc ��, -� Ft.
�� � �__r�.1s� 1��. F�. 1��.
Casing: Dcpt}i: From _�to_.�_Ft. Diarnctcr: ��- Inches
TYP�: Stccl Galv.�.i�izccl Stcc;l ..-
'If Stcel, docs owncr :�pprovc: j�'c;; No
Weight:�_ ' • — .
�I'.�iickncs�:__�_�-�=I����lt AUovc Ground:� jnches
Drivc Shoc: Xcs__ v'� No - ,.
Wcre 1'roblei��s Encotintcrccl in Sc:ttinb t11c Casing? Ycs No �
r �
c 'ycs" �;ivc rcasoi::
Grou[: Type; Ncat _ Sa�icl/Ccu�cnt � Coricre[e � � � • �� •
Anrtular. Spacc Wicl�h 3 U1c}��S
Watcr in A.nnular Sj�acc: �.'cs '_.— IVo
�_
Mct��od: I'umPcd 1'r�:ssu� �. I�au�c:c] .._-- �� •
Dcpch: From C`` tu �� t"�•, __
Matcrials Uscd: Nu.l3abs 1'ortl�uid Ccmcnt '
Zf mixture sand, ir<<vcl ct�ctin�� • ---�-- wcight of.l bag�_lbs.
� b � �1� •- �Z1i10: . �. _ IO �
�ID Plates: Yes �.� N� - � . . . _ �.
� 4 x 4 slab �'cs ✓ N�� � � � ' .
---_ I�RILI_,I NC i _(�.
De th
Fx�m �To
Forrnation Dcscripcion
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I HEREBY CERTTF�' THAT"['I-IE �A,130VL 1NFORMATIO SI ��
J�,
THIS WELL WAS CONSTRUCTLI� iN ACCOxU�CE WIT i ORRECT ANDTHAT �' �'R�j
REGULATIONS�'SET � ,�' �a�
��RTH BY�THE PEIZSON COUN7' �� I-ILALTI-I DI;PARTMENT. ��`�'�
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.Si��illlllliC nr ('orlcr,ictor ------ ! � �:,,�;:�
Datc
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