A25 194,
Amount paid ,�,��,00
Receipt .1i � l�o�;q
_ .,
F. - 2 � ,r.c� o
Date
B acteria
l, permit requested by:
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Chemical
�ective owner/agent:.
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ome Phone #: ��6 - �'g�' ' � 3 r'�'
usiness Phone #: '� � b S"9� - 3�i t�
_.__... _
Petroleum Pesticide —. �a
7. Dimensigns or Proposed Structure:
Width: �Zd
Depth: �- 4� �
�� 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?
Name and addre�s of curren[ owner: 9. Water supply type: "
� ' s, y,,.,, private �'. public ❑ community ❑ spring ❑
� Are any wells on adjoining property?Yes C��" No �.
If so, identify location: m� L--�-� �c�-'° w
Description: Lot size: �_ -
Tax Map#:=�.'��
Parcel#: � �� _
. Directions to propercy: State Road #& Road
���
Vti't
Number of occupants or peo
m c (}l..�i' �
` G[ %�- - i �oo �...
�le to be served: �
10. Type of structurelfacility: Proposed: C�Existirig: Q�
Type of dwelling:
House: � Mobile Home: C!�3usiness: ❑
Type of business: �
Number of Employees: — : _ ::.
Number of bedrooms: � �
Garbage Disposal? Yes � No �l �.- -
Basement? Yes ❑ No�f so, # of basement fixtures
v CLEARLY STA� ALL CORNERS OF THE PROPERTY AND THE CORNERS OF. ALL
�PROPOSED STRUCTURES. - �
I hereby make application to the PerSOrl_COun�y. T3ealth Department for a site evaluation for the.on-sit�
sewage disposal system for the above described property. I agree that the contents of this application ,are-tcue
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 tKat before an Improvements Pemiit can 1-
issued, I must present a survey plat of the propercy to the Health Dept. I understand that in the event I have nc�!
delivered a survey plac of the property to the:Health_De t. within 60. DAYS after the date of the evaluation o{�
P
the site by the Health Dept., this application shall�become void and all:fees paid forfeited.
. v�� ,
Signcc� Owner or Authoriz d Agent ��
Permit Issued ❑
Permit Denied ❑
Plat Obsei-ved ❑
1. SLOPE (%)
Signature
Date _
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g 2563
PERSON COUNT'Y HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # �}- a Cj Parcel # �� y
Zoning Township �( tn. f1i G%,C� M
Owner/Contractor (�,���1 � �p�►� ate (b—
:, Location/Address �`7 f1! � i I� L� t��n�r—� C,�J�-,F�o '�( -�-r� �,n� � L
' ll t�i�0 1 �-t— �.� �Zl S.R.#
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area�� Size of Tank �
SFD �Mobile Home l� Size of Pump Tank
Business # of Bedrooms � Nitrification Line >`)(� '
Max Depth Trenches o� ''
Permits may be voided if
Well and Sep Layout by_
Comments: �,Q�
Date
ell Permit Pai
Installed by.
altered
�Semi-Public
Replacement
te Approved
ell Head Approved
•outing Approved_
Comments:
Date
Installed by.
changed.
0
� Approved by
�� � a2o2-d6 �'Ir�
SYSTEM SPECIFICATIONS
Required Slab _
Air Vent
Required Well Log
Well Tag
Approved by
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This report is based in part on ioformation 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 conditioas 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 Ol/95 rev.l.l
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AUTHORIZATIOI�I FOR WASTEWATER SYSTEM CONSTRUCTIpH
(Void sixty (60) months from date of issuance)
DATE: IZ��� '� g BviPROVE1ViENT PERMIT ##: �o
TAX MAP #: � PARCEL #: ( Q
OWNER/OWNER'S REPRESENTATIVE: ��
LO CATION/ADDRES S:
�
SUBDIVISIONI�IAME: LOT #:
SECTION ORBLOCK:
AUTHORIZATION FOR CONSTRLJCTbOI�I ISSUED BY:
AUI'HORIZATIOI�I CONDITIOI�IS
1. The Wastewater system construction and installation must meet all of th conditions of the
attached site plan and speci&cations as set forth in Improvements Pernut �_�. The
construction and installation must also meet aIi applicable rules and Iaws.
2. No portion of the Wastewater system shall be covered or placed into use unti[ inspected and
approved by the Person County Health Department.
3. Any alterations in site or soil condifions rnciuding structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specifced in the associated improvement
permit and apptication, may void this authorization and associated pemiits.
4. Conditions:
Person Requesting: ���1��"''