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B 2651
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION INIPROVEMENT 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 # � 2-� Parcel # �("l
Zoning r�ownship rl �1 i,'2 A%�-rr�
Owner/Contractor ate I Z 2) — 9�
Location/Address S r7 nl `i"IQ C nr►cc� r�f � C�-�-�, �T��- �cC-�kee :s M� L I�.
i S.R.#
Lot# �
0
�,,. SEWAGE SYSTEM SPECIFICATIONS
Lot Area �� �j,4-� Size of Tank l O
�- Mobile Home I� Size of Pump Tank
# of Bedrooms 3 Nitrification Line ��' )C3
Max Depth Trenches I � "
� ���N`�O�P�/C� }�1S
Permits may be voided if sit ' Itered or intende se changed.
Well and Septic Layout by
Comments: �.�n� �'O�Q� '�f�3 �YvLQD�C �.i �Q ��-i-P1Z. ��
Date
by ��(;.a r r�',�"-}� ,� Approved by,
'ell Permit Paid. , WELL SYSTEM SPECIFICATIONS �
dividual_�Semi-Public Required Slab/
�blic Replacement Air Vent
te Approved �/ �2S /D �- � oo Required Well Log�
ell Head Approved r� 1� /o �- c� Well Tag vf�
-outing Approved kort' W �TN�SsED �Q ��.p-ti-' �/Z� �
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This
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 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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Lo�aiion/�irecu0ns:
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PERSON COUNTY ENVIRONtiENTAL H£AL'CR
WELL LOC
SR# '' ' a
Subdivision N�tme: _ r-oc #
�rilling Cbn�acior: �r ���..�� c�..��� � b��, ,.-'�"'nc .�..
VVELL CONSTRU�'IQI�i
Distance from Nea�est Properry Line � d Discance �`rom Source of
�Pollution c G o
Total.TT?ep.th:� � 20 , Fc. Xield:!_,� CpM Stacic 1��ter l..ev�1 � F�
Water Bearing Zones: Depth ��r�. ¢ Z. Ft�F�. �i.
Casi�ng: Depth: Fzom�to_�wFt. Diameter: l�Y.,� Inches
TYPE: Steel • Galvanized Steel / '
If St�el, dees o�ur-r: aP�:oVe: Y�s� No�
� � Weighti � xhicicness: �.�' HeighrAbove Grdund: I�l Inches
�rive �hoe: Ycs �� No , '
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Were Paroblems Encounterod in Settin� the CasinQ? Yes� N� •� '
. IF "ycs" givc r�:a.son:
G��,ut: T;yp�: �veat Sa��d�'���r�zr�t i Concrete
Annular Space Width �zich�s
Water in Annular Space: Yes � No
_ .:�!:'�}:C�: P"�".''.rtw..� - D::=.S.C.'-1.T�_....:,,,�,� D�"4"l� � �,;,,� " .
De�t3i: F�vm C3 .o C� Ft �
lViatenal,s L1sed: i`�o. �iags 1�ortland C:emcnt �eighc of .1 bag„_,.,_ibs.
Yf mixctue (sand, gravel; cuctinas) • Ratio: to
�In Piates: Ycs l _ _ No.___.� �
� + � � sla`�u i � �_ iva_______�
i H�REBY CERTIFY TT�ATTH� AB�VE INFORMr�TTON IS CORREGT ANU THAT
TH�S �1�LL uIAS C�JI�tSTRUCI'�D LN A�CO??�,�CE �lr?':? :�E�i}LA�'i��tS S�T
�ORTH BY�THE PERSOv GO'vi�'I'Y HEALT AEPARTMENT.
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'I'ype �dI (lb) Systeffi dxispection Cheeklist
Tax Map �� Parcel # : `7 PIlV
Owner: r G1- Sub ivision: �
Address: Sec/Lot:
Location: , -9 /ls�, r . .F '
1_)_.Establishment___ ____.__..._ _.
a) type, size and sewage flow in
accordance with permit
2) Tanks
a) tank risers accessible and surface
water diverted
b) tanks and access manholes structurally
sound, watertight
c) sanitary tee(s) in good worlcing condition
d) tanks pumped, cleaned out as needed
3) Effluent Dosins Svstem
a) effluent appears clear, free of excess solids
b) required pumps present, operating properly
c) high water alarm present, operating
properly
d) floats, pipes, valves, disconnects in good
working condition, operating properly
e) control panel enclosure and components
in good condition, operating properly
fl Drawd'own rate: i" �d cP�
4) Ground Asorntion Field(sl
a) no evidence of effluent reaching surface
or surface waters
b) surface water being effectively diverted
away from drainfield
c) diversion ditches, swales, tile drains aze
well maintained
d) soil cover, vegetation adequate and
maintained as needed
e) protected from traffic and destructive uses
fl distribution devices in good condition,
worldng properly
g) repair area properly reserved, maintained
h) pressure head properly adjusted ....
YES NO Remarks
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Summary of Improvements and/or itepairs Needed:
Authorized Agent
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�Amount paid �,SQ .
Re.ceipt ,� ' (�,
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Date
Improvements Permit. (Fstablished/Recorded Lot) _ Reinspection of Existing System (Loan Closing)
ImuFovements Permit (Unrecorded Lot) Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) _ Permi[ for New Well
Improvements Permit (Addition) _ Replace Existing Well
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1. Permit requested by: . 7. Dimensions or Proposed Structure:
owner/prospective owner/agent: /�-! a.. Width: �.�
Address: _ �!fi._ %� g-,�34Z Depth: (�F
�o � .�' 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?
Home Phane #: S5 �' -- 03s r" �/'�
usiness Phone #: �'g `� .—.��'Q °
2. Name and addre�s of,current owner: �/�o...� 9. Water supply type:
� private � : public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No (r�--
If so, identify location:
3. Property Description: Lot size: .�. S'-.�9�'•
. Tax Map#: �i. -�- S"� 10. Type of structure/facility: Proposed: �"Existing: Q
Parcel#: Type of dwelling:
Township: �� .� L— House: ❑ Mobile Home: C� Business: ❑
5. Directions to property: S[ate Road #& Road Type of business:
Number of Employees:
ames,�tc. ��� ,.�� �g/1 Number of bedrooms: �
: s,� .� 16 C � � .
•�� � � a �, Garbage Disposal? Yes C� No 0
a� � Basement? Yes ❑ No�I If so, # of basement fixtures:
5. Number of occupants or people to be served: �
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CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS U�� A.LL
PROPOSED STRUCTURES.
hereby make application to the Pet'Son COunty He31th Department for a site evaluation for the on-site
�ewage disposal sys[em for the above described property. I agree that the con�ents of this application are true
ind represent the maximum facilities to be placed on [he propercy. I understand if the site is altered or the
ntended use changes, the permit shall become invalid. I understand that before an Improvements Permit can be
ssued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
ielivered a survey plat of the property to the Healih Dept. within 60 DAYS after the date of the evaluation of
he site by the Health Dept., this application shall become void and all fees paid forfeited.
Signcc� Owner or Authorized Agent
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