A25 34A�
Amour.t paid �b� �O
Receipt �� ��
r•
� � �
, 0� �
,�6 � red� �
C
C ad �
Improvements Permi[. (Established/Recorded L,ot)
ImpFovements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permi[ (Addition)
O s : ' � �> e"+ei.'f' » '.�v"'3 ,'�sM^w•ef.;E,,�e^
,� -.`,'1. "� "..iµa ` t1 s li..y7r � Z�.il'h
^3.., . � t w ,+°'v. �."};L....rz.�y"
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B acteria Chem
� l. Permic requested b : .
owne rospective own lag�
� . Address: �
a�3� ' � 1
� n, n. fl � �-1
�:
� Home Phone �: J " S�I l3
� usiness Phone n:
W
¢
z
�� ��Ob �`� �
aa ��ia
:-�:.' ,
�-�`��
Date
Reinspection of Existing System (Loan Closing)
_ Reoair/Replace existing Septic System
_ Permi[ foc New Well
_ Replace Existing Well
�
7. Dimensions or Proposed Structure:
, Width: a�
�a Depth: u
— 8. What type (if any, additions, expansions, or .
— replacement is anticipated to the structure or facility
— that this sewa�e disposal system is intended to serve?
�co�' e �-d'
and addr of_curren[ owner:f
1 c� n i n6 � � n, l-�- ►� �'.S I i\ i� h�' v' �;
Description: Lot size: a� 7( �F(:Ye � i�
. Tax Map#: 'E' � �
Parcel�: �
Townshio: � �.�uJ.� �.� L o�11��-
Directions to propercy: State Road #& Road
r,�es,�tc. � I —� ,�,,I 11v�
1-�rrh�� . A�i-1-»n1
0
9. Water supoly t5 pe:
private t�. public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No (_'�..
If so, identify location:
10. Type of structure/facility: Proposed: �xisting: Q
Type of dwelIing:
House: � Mobile Home: (�'usiness: ❑
Type of business:
Number of Employees:
Number of bedrooms: � �
Garbage Disposal? Yes ❑ No �—
Basement? Yes ❑ NoQIf so, # of basement fixtures:
�6 Number of occupants or people to be served: �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY A1�ID THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make appiication to the PerSOn COunty Health Department for a site evaluation for the on-site
sewage disposai system for the above described property. I agree that the con�ents of this application are crue
and represen[ the maximum facilities to be placed on the property. I underscand if the site is� altered or the
intended use changes, the permit shall become invalid. I understand tha[ before an Improvements Pecmit can be
issued, I must present a survey plat of the property to the Health Dept. I undecstand that in the even[ I have not
delivered a survey plat of the propercy to the Health Dept. within 60 DAYS aftec the date of the evaluation of
the site by the Health D�t., this application shail become void and atl fees paid forfeited.
iQipca Owner or Au�horized Agent
� - -
. %
� . . g 2802
� 4
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a
PERSON COUNTY 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 # � �� Parcel # �J �'i�%
Zoning Township If� `�
Owner/Contractor � � �
Location/Address S-1 N ��,L. (iQ►7C� � - C-'-
Subdivision Name
Lot#
S.R.#
�e
SEWAGE SYSTEM SPECIFICATIONS
�ir Lot Area ��'j ( �� Size of Tank �' � �-�2�
� � Mobile Home L� Size of Pump Tank
ness # of Bedrooms�_ Nitrification Line �X.3�
Max Depth Trenches �-4 `'
Permits may be voided if site is
Well and Septic L�� �.�E
Comments:
,� .� �i� �,��
r intenc�ed,t�� changed.
Date , 3- I 1- �9 Installed b�`��i�'p � Jt� Approved by
Well Permit Paid WELL SYSTEM SPECIFICATIONS
`
Individual �emi-Public Required Slab
Public Replacement Air Vent
Site Approved ,/ Required Well Log C��. _
Well Head Approve �Z3-'`� Well Ta
Grouting Approved �j -
Comments: d � 2 �
Dat ��Z3-� Installed by Approved by
This report is based in part o� 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 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 Couaty 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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leon C. k Malinda Roach
Cordon C. & �ertho A. Soulhem �•9• 233-848
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01/19/1995 18:21 80a45a78a3 BENNETr wELLDRILLING PAGE 02
FERS�N COUNTY �N�'JRON'I�:��'r^G N�aL'i�-
�'ELL i.n��
I)atc:,�: ��. -�`!
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w�r.�, c0�,1S7�tt1�T1.�
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�1�:�c�r I3euin� :Loncs: t�ep�it !'�. __.�_�'�-_ _...__.r._�'t..__, Fl,
C'asing: Deplh: F't��rn.._„�„___10 ��2 Ft. ��iamct�i _�.,/� G�c hc5
7'Y7�F.:: S�eel .-. -- -. - - 4alv�nizeci i�e�el !f.._ _.... _ _. ..�..- - .-
Xf Stcc�, dc•�s Awt1�t �QptOve: Yes,�.,....,.Na „.__
Weighe:1� T)uickness:/�,�_ .Ncight Abo��e C,�rc►��nd:���.�_Inches
[.hi�e Shoc: Yes ✓ No �
�Vere iirs�bl��mc Enc��mtered in Settin� the CuinK•' ��cs..��.....�-- iV� V'-..
7� ���'CS�� �l��C j�Y5011:..... ,- - -----�,...�--- ..____.. . .,_.�. .. _ _
f ,rc�ut: �iy��r: %leat__ ,1% .�. SandlCemcn�,�_ .. _... _'�'o;,rrrte� - -� � �
Annula� Space Widlh_._. .� ������cs
tiVater in Artnulu Space; Yes �_ i1o�t�____
Mc�had� P�unped_.t�..� ArPssure� --,..��,_ Poured__...._---.�
[)epth: Frc�m_�,_ �� lo � U_ w�=t.
,Materials Uscc�: Na. Bags P�nland Cenicr�c..._�,_ 1ti'ei�,ht of 2 ra� ,� lt�s.
U m'uccure isa�id, grayel. ctactings) - Rati�:��.�......�,. :o-
�U Places: Ye5 ✓ N� . . .�_'
Q x 4 slab Yes_.�,_i � No„_,_,_
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