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I ovements Permit (EstablishedlRecorded Lot)
mprovements Pecmit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
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Bacteria
. Permit requested by:
owner/prospectiv � wn�
Address:
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Reinspection of Existing System (Loan Closing)
Repair/Replace existing Septic System
Permit for New Well
_ Chemical � _ Petroleum
ome Phone #:
usiness Phone #:
. Nam Aand address of��
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Existing Well
_ Pesticide I ._. Lead
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L 7. Dimensio s o• Proposed Structure: '' -
C��� Width: I�3�j-S ('� - ����
" Depth: % � .�t ��
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-�--- 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?
; 9. Water supply t} pe:
'' private , public ❑ community ❑ spring ❑
Are an�wells on adjoining property?Yes ❑ No ❑
If so, identify location:
. Property Description: Lot size: /'Cr «�
. Tax Ma "fi
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Parcel#•
Township: � ` � '�u�� ��
n,? ta rr� c,;���
�. Directions to property: State Road #& Road
, etc�� ' ��`t �
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. Type of structurelfacility: Proposed: DExisting: ❑
Type of dwelling:
House: ❑ Mobile Home:�l Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �_
Garbage Disposal? Yes ❑ No C�
Basement? Yes ❑ No� If so, # of basement fixtures:
6 Number of occupants or people to be served: �_� �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
'PROPOSED STRUCTURES.
I hereby make application to the PeI'SOri COUI1ty Health Department for a site evaluation for the on-site
sewage disposal system for the above described property. I agree tha[ 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 becom void and all fees paid forf ited. � u
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permit Issued ❑
Permit Denied ❑
Plat Observed ❑
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Signatur Date �2'�� . - •
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I. S(APE (5F) ; S S 5
PS D� PS PS PS
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2. SOR.TFY.NRE(12•36IN.) S S S
tSANDY. LOAMY. CLAYEY. NOTE 2:1 CIJ11� � Gr� � . � �
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3. SO1L S77tUCTURE (IZ-36 [N.) �n S S S
(MYEY SORS) PS s L#f l PS PS PS
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d. SOIL DFP7'FI (IN.) S ���� S S S
PS PS PS
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3. RESTRICTIVENORiZONS(TN.) S S S
(ASPFRYIOUS STRATA. ROCK) PS � PS PS PS
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6. SOQ.DRAINAGFJGROUNDWATER � S S 5
(FJCTERNAI.& VV�I77'FRNAL) �� � PS PS PS
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7. SOQ.PERMEABILlTY S S S
(PERCOLAATION RA7� PS �?� PS PS PS
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E. AVAII.Ag(E SPACE � S S �
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9. STIECLASShIGiION(SEEBELO� �S
SOII. SERtES
SSUITABLE PSPROVLStONALLYS ABLE U-UNSUITABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRA.M (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
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PERSON COUN'T'� �HiEA.LTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIl'ROVEMENT PERMIT'
B 1079
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i�3t for waste water system construction. No permit(s) for Construction Location or
Relocation Activ:ty shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # oC,� Parcel #�
Zoning � G, � �-1 .. . ,- �WnS111p
Owner/Contractor r"
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Location/Address � rI nl �
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Name � Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area � �Y Size of Tank w�
SFD Mobile Home Size of Pump Tank NIA
Business # of Bedrooms�_ Nitrification Line /�D D ��C 3�
Max Depth Trenches 2 �,, � �
Permits may be voided if site is altered
Well and Septic Layout by
Comments:
Date �.S I ,
Well Permit
Individual
Installed by,
Site Approveti /�
Well Head Approved
Grouting Approved_
�niei ae use c� ngen.
,
,� Approved 1
�FoC. `-/-1— 1 / W�N
SYSTEM SPECIFICATIONS
_Semi-Public Required Slab v
Replacement Air Vent
_ Required Well Log
� Well Tag _
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Date
This report is based in part on information provided th� homeowr�er or his/her
representative in the application submitted for this permit. The environmental
health specialist is not t•esponsible for false or misleading infurmation
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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CONTROL CORNER
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L am ( e are) the
�wn and <iescribed
� me (us) by deed
_y Register of.
�ge ��nd i:hat
in of subdivision
establish the
declicate all
irks, and other
vate use as nc>t �c1
�y that the land
�e sul�division
'erson County,
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Moriho E Winsteod
� B 156 - 128
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Date:_3 -3i-g� ' ^
Owner: �e
Location/Directions:
Subdivision Name:
Drilling Contractor:
Distance from Nearest Yroperry Line__ �O Distance from Source of
Pollution ,��o '
Total Depth:� � Ft. Yield: � GPM Static Water Level s Ft.
Water Bearing Zones: Depth 9v Ft. 4�sJ � F� �G �� Ft� �t.
Casing: Depth: From O to 8' ! Ft. Diameter: l' %, Inches
TYPE: Steel � GalvaniZed Ste�l �---
If Steel, does owner approve: Yes No
� Weight: � Thickness:� Height Above Ground: /� Inches
Drive Shoe: Yes � No
Were Problems Encountered in Setting the Casing? Yes No ,�
If "yes" gir•e r�:ason:
Grout: Type: Neat Sand/Cement .� Concrete
Annular Space Width Inches
Water in A.nnular Space: Yes No
_ .. Method: Pwnped - Pressure � � Roured ,� � - �
Depth: From o to a G Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag_`lbs.
If mixhue (sand, gravel, cuttings) - Ratio: to
ID Plates: Yes � No �
� 4 x 4 slab Yes .� . No
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCFED IN ACCORDANCE WITH REGULATIONS SET
FORTH $Y THE PERSON C�JiJTY HEALTH DEPARTM .
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Signature of Contraccor Dat�