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A25 184,� , -. �. �����° ^ � 9 y � _ . . � � • _ � . � APPLICATION FOR SERVICES � � ; Ser�xr,�s l�equested . ,: :>: , , Improvements Permit (EstablishedlRecorded Lot) _ Reinspection of Existing Sys� � H O � � w U � a Improvements Permit (Unrecorded Lot) Improvements Permit (Mobile Home Replace) Permit (Addition) (Loan Closing) Repair/Replace existing Septic System Permit for New Well _ Replace Existing Well l. Permit requested by: 7. Dimensions or Proposed Structure: owner/prospective owner/agent: Width: Arirlrett� `�r _ Depth: ome Phone #:_ usiness Phone #: �ss of ��r._ �i�iw� Description: Lot size: Tax Map#: Parcel#: . Directions to property: State iames, etc. Number of occupants or # & Road le to be served: What type (if any, additions, expansions, or ,���ement is anticipated to the structure or facility hi�#sewage disposal system is intended to serve? 9. �upply t}'pe: private public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No ❑ If so, identify location: 10. Type of structure/facility: Proposed: DExisting: ❑ Type of dwelling: House: ❑ Mobile Home: ❑ Business: ❑ Type of business: Number of Employees: Number of bedrooms: Garbage Disposal? Yes ❑ No ❑ iBasement? Yes ❑ No ❑ If so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the PeI'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 propeRy. 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. z Signed Owner or Authorized Agent b -�.. y • i tiY Permit Issued ❑ Permit Denied ❑ Plat Observed ❑ Signature Date (� yPG���� � �� `�y I � e � � /�` 9�.' � . r y �'\ � � � ---5�� /33 . { , �O � �� ._ c�vz�% N v, d,"� h^°� /� _ i� S� �e �� ��,-e_ /�TY� % � �� � � � ���- )�1 � C�ws � �— siz � �3,�� FACn1RS-57I'E EVALVkTION. ; .. '_ . . . . ; 11RP1� t . AREA 2 r` ; ,4REA'3 ARFA � _. . _. . _ _ _ . _ 1. SLOPE (9F) S S S PS %�if� ��O D U U �� 2. SOII. TEX.NRE (12-36 IN.) ' S S S (SANDY, LOAMY. CLAYEY. N07E 2:1 CLAn PS �'b' ,f�1� U U U 3. SOIL STRUCTURE (12•36 tN.) S S S (CLAYEY SOILS) PS �„/)�/{ PS PS PS / l/� u v u 3. SOII. DEPTH (IN.) S S S S �� /� PS PS PS U U U t, RESTRICTIVEHORtZONS(IN.) S S S S (IMPERVIOUS STRATA.ROCK) PS � Nb PS PS PS U U U 6. SO[LDRAINAG&GROUNDWATER S S S S (EX'[ERNAL dc INfERNAL) S A(,D PS PS PS � �I U U U 7. SOIL PERMEABILI7Y S S S (PFRCOLOATION RATE) P `?� PS PS PS U U U U 8. AVAILpBLE SPACE ,/ S S S fLt' PS PS PS U ��� � U U U 9. Sl'CE CLASSIFICA710N(SEE BELOR� ,� SOIL SER[ES SSUITADLE PS-PROVISIONALLY SUiTA6LE U•UNSUITABLE RECOMMENDATIONS/COMMENTS: SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope patterns, etC.� C:WMIPRO�DOCS�APPSEC.SMFINANCE.PC � ai AAP � �i � � �� NILLIJuI G. flNtLET ' DB 224 P 783 � ai � � � ! � � � ` �• � ' t34. I I° �—ftCt'11 �63`E , 29.53' a�g � , A � �_.s'v%i ���� � � 1. cio /�c . vv..�.��.v� . X� JUNE i995, F � ��O • NE , . e� �� . �� � , . . , � MF ` 1 '. : r r ,� '' �° ,� • �,� ! �� i 1 tt Wt (�r , ��- �. `--�vf1! iP •n��� ���Q ...... 1 �- trti ��� � �` ` _"" ..,,. _.....ti_.._ . �,� g� ta o . �``�'�� ... -- --- --......-- � ` � ?°v, � � , � . \U'/�-' b i �� �� ►� '. � � � �, �, . � � . 4� AC. �,����' �'t�. e � +\. 1 � ` . �"�� , � ^T �� � �. �� �� .+ '�i. �� � ���� �� �� pp �� f�" • �4� l, . .��'i . ♦ . , `� vr�1� h� , -,` �of 3 �� ���. • ,� �� ♦ `�� � .}� . �� J�� . ++� r5 -� ��`` !� � �U "1 � ? "�. � � l.>' � �° �'s� �� � : ��� ,. s,t :s `Ga ^ LS° ,`� LS NS1 oE�u.oave c sotoYar ._.. --.._'....'-.._ 0.8. fat�P�749 , . +�7ttlµ 6. QtkLPY O.H. �• �• l7t A 001 042 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGF SITE, LOCATION IN�ROVEMENT PERNIIT Tax Map # � �,S Parcel # � � � Zoning Township ' � �^�� Dat �- �- �/� Owner/Contractor '�,`: a.nr�, GL,�..��. % � �� Location/Address � �����3 „-� � %3 `7 vn +� V� S.R.# 1.33'7 Subdivision Name r,, ) i � � i' A rvi ir� y���i ��.n Lot# [�) SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area /� U �� �.t� � SFD �/ Mobile Home ► Business # of Bedrooms � Size of Tank � � Size of Pump Tank Nitrification Line ' � Max Depth Trenches �' Permit Void after 60 months. Permit Void if not in compliance with zoning regulations. Pernuts may be voided if site is altered or in nd use changed. Well and Septic Layout by Comments: �!`Q. c�� �r, Date 9 Installed by Approved WELL SYSTEI�Z SPECIFICATIONS 3ividual � Semi-Public Required Slab _ �blic Replacement Air Vent te Approved Required Well Loo ell Head Approved Well Tag -outing Approved Comments: Date Installed by Approved by This report is based in parc on information provided the homeowner or his/her representative in the application submitted for this pernul The environmental health specialist is not responsible for false or misleading infotmation contained in the application The environmental health specialist is also not responsible for concealed conditions on the property or for statements in this repoR that may have tesulted from false or misleading statecnents provided to him in the application. Neither Petson County nor the environmental health specialist wairants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�permitsam O 1/95 rev.1.0 ]+ � �� . � `\�\ U��O O�� � 1 {'. r ' : ��. ,.\ � �s� '' �, , ` � ` ' � � t�- ' � qC. . - �� , f{ f ` ' 4�� � � +' . ; . 1 '.... ' . t J .: Y ' � 1 F' -J , �'�P . / ,r� �� , . /: . � e �'�- ljj p� � , � SF- � n � � �` I1x.�j v 1 ' ��� •J :, j � , t :� � t �M1I" .Y x ` . bj . ' '1: '. � �14,r: •�r . * . _ .F ;�... S, . . � ' .,; ;r'� . s�r ;f�._: r Y. ' • �� �.. � . r t f . �. )A l•y 7�t` � ! • . ' . Y . _f .'�� F. .r., �+�, . � � .� �' � a f��� . ` �� FY .p C • :1�IF' �. ' �' ' ' � \ • ._ . �'� � �t)• . ` . � a , �o s�- �, _ ' � ` �� t ° � � �- f , �s�, �-- � �.6-, 1 . . �' � , -_ - \ N�, � - � � O� O' ` ` 1 ., � t �. �' � � ,e' 1 � .. . ..�� '�\�.t� � ti� {� •`� 4, �''.. pr } d �� a ' .1�` �� '.!"�� �' : , ^ �t, T r , f , `' � , '�1 s,r •:" �rr . 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