A25 196Amount paid ;��o.00
Receipt .1d � {o20J'�1
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1. permit requested by: . 7. Dimensions or Proposed S[ructure: I
owner/prospective owner/agent: �^�i¢ ��^- Width: �/�� _�_
. i'1 T_��L. /. _
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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?
ome Phone #:3,,�6 -' �g�-- 0 3.�'-t'
usiness Phone #: �3-6-.�"�t�i'— 34'��I'°
. Name and address of current owner: 9. Water supply t}'pe: "
� ��� _ private f� : public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes � No Q.
If so, identify location: �'o • ��� ``O "
Descrip[ion: Lot size: !• � ��°•
Tax Map#:
Parcel#: .
Township:
Directions to property: State Road #& Road
ames,�tc.
: .'� 1`! i"n C
O a b� �� 7'� �" D� .
10. Type of structurelfaciliry: Proposed: C`�xistirig: Q�
Type of dwelling:
House: [�Mobile Home: C�'Business: ❑
Type of business: �
Number of Employees: - :... :.
Number of bedrooms: __.�_—
� Garbage Disposal? Yes C`�" No E7 �-
Basement? Yes ❑ Noi�'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 PerSon:COunLy. Health 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 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 tliat before an Improvements Peiiriit can 1:
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have nc�?
delivered a suc�yey plat of the property to che:Health_De t. within 60 DAYS after the date of the evaluation of
p .
the site by the Health Dep[., this application shall become void and all:fees paid forfeited.
,,� .:.,
Signcc� Owner oc Authoriz Agent
Permit Issued ❑
Permit Denied ❑
Plat Observed ❑
Signature
.�
Date � '
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RECOMMENDATIONS/COIYSII%IENTS:':�" � �` -. . � . . . :: i'a: ., ,�:;s:�.li �`�. .
SITE CLASSIFICATION DIAGRA.M (Include: Soil areas, property lines, roads, streams, gullies, wet areas;.:fill ;=u
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o = oT�o'»N
R = 1167.l8'
T = 78.24'
L � f66.26'
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— �oo.00'
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Chd, Dis�t. — f25.90'
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R = 1187'.18'
T = 83.04'
L = �z5.ss'
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
2555
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 # ,�' � J Parcel #_
Zoning _ Township
Owner/Contractor
Location/Address
i .� ►i . . -
Subdivision Name
� � b
� Date Ih- 1-
�� d-l�.QP s n
S.R.#
Lot# �
SEWAGE SYSTEM SPECIFICATIONS
Lot Area `� a���
Mobile Home
# of Bedrooms ,�
Permits may 6e voided if
Well and Septi ayout by_
Comments: �
Date Installed by.
altered
Size of Tank�Cx
Size of Pump Tank�
Nitrification Line�L
Max Depth Trenches.
ed use changed.
Approved by
Well Permit Paid ❑ WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab
Public Replacement Air Vent
Site Approved Required Well Lo� �/ �nl �4 S3 -9�
Well Head Approved Well Tag
Grouting Approved ✓ S� 5-3 ' `� �
Comments:
Date -a - q 9 Installed by , Approved by
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 ioformation
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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8. 53'
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N84'01 '12",�
Totacl — 3'�►3, 80'
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Toia1: _ �18. � `
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a" � . .
l�arne�, Jr.
�a� . � Q
A � � �1:.w�� � � . ��
463.89'
- ---• iv
� S D?"40'>9"
R = »s7. �8 �
T = 78.,24'
L = �ss.zs �
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�oo.00�
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l��so'
c�. 8,.�. _ ,
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.
0 = 06'11'00"
R = 1167.18'
T = 83.04'
L = >.25. 96'
>336
R/�
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PERSON COUNTY ENVIROIZMENTAL HEAL
. .. .. . . _ . __- _ _ . . -� - - - _ _. •_. �
. _ TH • . -�
• • . , ��: s e.
' � ' •• � WELL LOG . • ''.
.. • ' . . • . ..
,r . , , � .
Date: ' ' � '
Owner. � � � _ . ___ _ _ .
SR# ' � � .
Location/Directions: T � � . �
�'1� �__L L�� r� �D r°-st- �n� � c+� 1 C c�� ['� r--�r. I
Subdivision Name: __ Lot #
Drilling Contractor: a e c� /(' 1,e�(l,.�q. ���/ y
Distance from Nearest Properry Line Ic� Distance from Source of
Pollution .(C�C'� `
Total Dep.th: z_�_ Ft. Yield:�_ GPM Static Water Level Ft.
Water $earing Zones: D�epth8��-�Ft.��� � F� �t.
Casing: Depth: From c� to � Z Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel ��
If Steel, does owner approve: Y�s No
� Weight�: � Thickness: !�k Height�Above Ground: 6�i Inches
Drive Shoe: Yes ✓ No
Were Problems Encountered in Setting the Casing? Yes No �
II' "yes" gi�e r�ason:
Grout: Type: Neat Sand/Cement ,/ Concrete
Annular. Space Width Inches
Water in A,nnular Space: Yes No
_ .. Method: Pumped . . _ . �Pressure � � Pourzd t/ �-- �. � � • •. - :.
Depth: From O to �. c� Ft. . .
Materials Used: No. Bags Portland Cement Weight of .1 bag__lbs.
If mixture (sand, gravel;- cuttin�s) - Ratio: to
�ID Plates: Yes ✓ No � � � •- � .
"� 4 x 4 slab Yes�—No �
I HEREBY CERTIFY THAT THE ABOVE INFORMr�TION IS CORRECT AND THAT
T�S WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C�Ui�1TY HEALTH DEPARTMENT. �
� Z ---
�Signature of Con�raccor ace
�
�
AUTEiORTZATIOI�I FOR WASTEWATER SYSTEM CONSTRUCTIOI�I
(Void sixty (60) months from date oEissuance)
DATE: I�- (— Q� IMPROVEMENT PERMIT #: ��555
TAX MAP #: �-�� PARCEL #: I� �i
OWNER/OWNER`S REPRESEI�ITATIVE: �
LOCATION/ADDRESS:
SUBDTVISION I�IAME:
SECTION OR BLOCK:
LOT #:
AUTHORIZATIOI�I FOR COI�ISTRUCTIOI�I ISSUED BY:
AUTHORIZATION COI�IDITIOI�IS
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 Pernut # ��"�� The
constniction and installation must also meet aIi applicable rules and laws.
2. I�Io portion of the Wastewater system sfialt be covered or placed into use uniil inspected and
approved by ihe Person County Health Department. �
3. Any alterations in site or soil conditions (inciuding structure Iocations) 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 pernuts.
4. Conditions:
Person Requesting: