A25 185�
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Im rovements Permit (EstablishedlRecorded Lot)
mprovements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
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�OR SERVICES • �
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Reinspection of Exis[ing System (Loan Closing) �
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_ Repair/Replace existing Septic System �
Permit for New Well
— —
Improvements Permit (Addition) I._ Replace Existing Well �
1. Permit requested by: �An el�a. D°'��s �'a"'�"<�
owner/prospective owner/agent: llma�-�� �. l,�u�e�
Address: � 1��� a d-y �� ' L� �"� Z
iL �,( b vzs a, l�• C- �7S ? 3 .
ome Phone #: -s`� `l-?�� � Z
usiness Phone #: `t�i- ��� �
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7. Dimensions or Proposed Structure:
Width: /S ���'
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8. What type (if any, additions, expansions, or
replacement is arrticipated to the structure or facility
that this sewage disposal system is intended to serve?
and address of cu ent owner: 9. Water supply t5•pe:
��, �, s fe private�l public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No ❑
If so, identify location:
: Lot size: l ac `e.
. :� 2 � �u,,,�, :i � -' �'.F
. Tax Map## � �' � e � ,
Parcel#: � �,
Township: ' '
. Directions to property: State Road #& Road
iames, etc.
S�_ � 3� b �. CcN Ce�d Ce,�6
i. Number of occupants or people to be served: Z
0. Type of structurelfacility: Proposed: �Existing: ❑
Type of dwelling:
House: ❑ Mobile Home:.� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �_
Garbage Disposal? Yes ❑ No �
Basement? Yes ❑ No � If so, # of basement fixtures:
f''
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
pROPOSED STRUCTURES.
I hereby make application to the PerSOII 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.
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permit Issued ❑
Permit Denied ❑
Plat Observed ❑
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3. SUILSTXUCTURE(i2-36IN.) S S � S S
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S. RESTRICTIYE HORI7ANS (iN.) S � S 5 S
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6. SOIl,DRAINAG&GROUNDWATER S S S
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9. SiTE CLASSffTCAT70N(SEE BE1,0� j„/ C
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SOIL SERIES
SSUITABIE PSPROVlSIONAl1.YSllITABLE U•UNSUifABLE
RECOMMENDATIONS/COMMENTS: �� hl�
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SITE CLASSIFICATION DIAGRA,M (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
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PERSON COUNTY HEALTH DEPARTMENT
WELL E1ND SEWAGE SITE, LOCATION Il�II'ROVEMENT PERMIT
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B 1052
Not for waste water system construction. No permit(s) for Construction Location or
'-Zelocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # ��.� Parcel #
Zoning Township C,
Owner/Contractor Ti"m r� f� ti��i n c, e%i cc.
Location/Address S'� �l �c_ �r, �t- i� 1to
Subdivision Name
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�n ���,r Date 3-� 9 - 9 �
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S.R.# /3 �}Cj
Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area r v,2 c, C�'t s' Size of Tank y j
SFD Mobile Home �' Size of Pump Tank rv �r�
Business # of Bedrooms� Nitrification Line S'�O �)C 3�
Max Depth Trenches � �"
Permits may be voided i1
Well and Septic Layout by
Comments:
Date kl - ' ) �1 �
ell Permit Paid
Installed by �'r�M Approved by
WELL SYSTEM SPECIFICATIONS
dividual V Semi-Public Required Slab �/
iblic Replacement Air Vent
te Approved Required Well Log ____
ell Head Approved Well Tag _
-outing Approved
Comments:
Date
This report is based in part on information provided the homeowner or his/her
represeotative 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 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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PERSON COUNTY ENVIRONMENTAL HEALTH
. •: - -.- . -..- - _ WELL LOG - -- _ ., _; _ '_ . ._. ..- - ---
Date: ,.S -� -9�
' Owner: � „t
' ' L,ocation/Directio
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SR# _/3�/� �
Subdivision Nvne: ___ Lot #
Drilling Contractor: p, fi� � rr��r��
. � WELL CONSTRUCI'ION
Distance from Nearest Property Line /U* Distance from Source of
Pollution /G�� .
Total Dep.th: � Ft. Yield: C� GPM Static Water Level c�S Ft.
Water Bearing Zones: Depth ��Ft. F� Ft Ft.
Casing: Depth: From �� to�Ft. Diameter: G'�4 Inches
TYPE: Steel � Galvanized Steel �''
If Steel, does owner approve: Yes No
Weight: Thickness: ,/,�.5- Height Above Ground: ��/ Inches
Drive Shoe: Yes v- No
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason:
Grout: Type: Neat Sand/Cement Coricrete
Annular Space Width Inches
Water in Annular Space: Yes No
_ Method: Pumped _ Pressure Foured ✓ - . .
Depth: Fr�m G �o ,�C� Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag lbs.
If mixtuie (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes ✓ No � �
� 4 x 4 slab Yes No
I HEREBY CERTIFY THAT THE ABOVE INFORM�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH �y�THE PERSON COLi1TY HEALTH DEPARTMENT.
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ignature of Contractor Date
T • �
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: � � - IMPROVEMENT PERMIT #: BOl.�2
TAX MAP #: PARCEL #: �I�
OWNER/OWNER'S REPRESENTATIVE: �,�, o�i y,c %�i'lcie�, cc� �..o ,,� e �-ti
LOCATION/ADDRESS:
�7 N a,-�. -� .
SUBDIVISION NAME:
SECTION OR BLOCK:
LOT #:
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 Permit # �� . 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 alterations 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 permits.
4. Conditions:
Person Requesting: