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9�grson Cauntv Health Deoartment
Errvironmentai Nleaith Section
APPLlCATIOPI FOR SEi4VIC�S
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Parca! #: �-1 �
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1) Permit requesbed by: (awneda errttpraspective owner): � �.�
Home Phane: 7- � Address: Z �(/j�
Business Phcne: � s� rr,�,rn Nf �.7 3Lf �
2) Name and address of cumerrt ovmer. �E�/Y12Q _
3) Property Descriptton: l.ot s�ze: � Township: �]� i
Diredions to the property �nduding ro�d names and numbe
4) Proposed Use and Structure Des ri tiQn• answer each of the following questions:
a) Proposed �sting ❑ (���f-�'D Y'1
b} Stidc Built 1[,,,.fi�loduiar �, Si� e Wide o, Double Wde �
c) Number of Bedrooms• /V d) Number of occupants or peaple to be served:
e) Basemertt:� Yes �, No �If yeg, # af ba��cnent fixtures: . -
fl Garbage Disposal: Yes O. No�
gj Dimensions of Proposed Struciure: Width� Deptl�:��
S� Water Supply Type: Privat�w � orexisting �biic Q, Cammunity �, Spring ❑
. Are any welis on adjoining propert�? � Y�No � If yes, location
6) Please indicate Desired System , i ype: (systems can be ranked in order of your preferencs)
CornreMiar�al Modified Carnentional
Other (spec9fy):
_ Altemattve - (nnovative
/' .
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CLLl�RLY STAKE ALL CORidERS AND LlNES OF THE i'ROPERTY.
ST�4KE THE CORNERS aF ALL PROPOSED STRUCTURSS.
PL.F�►SE �►TTACH SURVEY P�AT OR SiTE PLAiV TO TNIS APPLICA770N
1 hereby make application to the Person Caunty Heatth Department for a site evaivation for the an-site sewage dtsposal system for
the above-described property. I agree that the conterrts of this appiication are true and represent the maximum faalities to be
piaced on the property. I understand if the siie is alterEd or the irrtended vse ct�anges, the pertnit shall become invalid. f understand
that as applicant, I am responsible for identiiying and markirtg property lines, comers and making the site aa�ssibie fer the
personnel of the Pessan Courrty Health Departrner�t to condud their evaluatians. I understand that 1 am responsible for notiiying the
Hea epartment ifi my property co�ain any we#lands as designated by the Army Corps of Engineers. �
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Owne or Legal Rep entative Date
PCHD, rev.10192199
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Person County Hea].th Oepartment
Existinq Sewage System Report For: Mobile Home Replacement
�dition
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Requestee: +
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Location/Directions:
Home Phon.e# � �a90
Businessx
"�ax Hap� �07.5 ��7
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O riqinal Permit Located /" D ,
Septic System Designed For: _ _
Kesidential V 13usiness Other {specify}
� t3edrooms # Employees Other
Uate �nstalled Water supply �
Type ot System
Nitrification Line �t,l! I�bL��
Tank 5ize
D�►o
-Q �� .
Certified Operator Required
On site wastewater disposal system sliowes no visually apparent
malfunction on 7 ��(�� .: �
Yermission is granted to:
According
Comments:
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the attached site pl
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Environmental Health g'�G.
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