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A25 59� e�(��-,�,1 �-}- A 17 7 3 �� PERSON COUN'rY HEAL'I,H DEPA.RTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Tax Map # ��. ,�, Parcel # � Zoning Township . Owner/Contractor � e,-I- e��,P rr; l I Date �-17— 9% Location/Address ��_� IV) (' �'-rh.eP S M�.I �.l�P S.R.# Subdivision Name Lot# SEWAGE SYSTEM SPECIFICATIONS Lot Size of Tank ile Home Size of Pump Tank # of Bedroorr� a Nitrification Li�}er� � Permit oid a er 60 mo . Permit oid if ot in Permi s may be oided if site is a r d r in nded Wel and Septic Layou y Co ents: Date Installed by Approved by WELL SYSTEM SPECIFICATIONS Individual Semi-Public Required Slab Public Replacement- ,/ Air Vent _' Site Approved � ��_ Required Well Lo� � Well Head Approved 71 Well Tag Grouting Approved - - Od Comments: � � ��i� ��atYYl ,�._._.11�P1:� J__ia�2 I�ate � Installed by K, (j�� Approved by Tlus report is based in part on information provided the homeowner or his/her representative in the application submitted for this pernut 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 repoR that may have resulted from false or misleading statements provided to him in the application. Neither Petson County nor the environmental health specialist wazrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c�amipro�pemu�sam O1/95 rev.1.0 ORIGINAL L i%6 �n��' � Date:a' �'� ' Owner. � Locatioi��Directions: Subdivision Name: Drilling Contractor: ; PERSON COUNTY ENVIit021MENTAL HEALTH ��= WELL LOG �'+�iiCr�iZ:l•L SR# Lot # WELL CONSTRUCTION `�' ��'-- Distance frara� Nearest Properry Lin� jC� Distance from Source of Pollution [ve� ' Total Dep.th: � O Ft. Yield: �____ GPM Static Water Level ��_r�. Water $earing Zones: Depth �_rt. Ft Ft� �t, Casing: Dept}i: From_ b to �5"Fs Ft. Diameter: �_jnches TYPE: Steel - Calvanized Steel� � If Steel, does owner app:ove: Yes No � Weight: Thic�;ness: 1$S _ Height�Above Ground:�_ Inches Drive Shoe: Yes ,/ No . Were Problems Encounterc;d in Setting the Casing? Yes No t� If "yes" give r�ason: Grout: Type: Neat Sand/Cement � Concrete Annular Space Width Inches Water in Annular Space: Yes No - -. Method: Pumped � - P�ressure � � Poured_s; � � � �. . Depth: From_ � to 2v Ft. � - Materials Used: No. Bags Portland Cement Weight of .l bag__lbs. If mixtuie (sand, gravel; cuttings) - Ratio: to �ID Plates: Yes �� No � � •�" �� 4 x 4 slab Yes �iNo � I HEREBY CERTIFY THAT THE AB OVE INFORMATION IS CORRECT AND TH AT THIS WELL WAS CONS'�RUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY�THE PERSON C�ui�'I'Y HEALTH DEPARTMENT. . ��_ ignaturc of Coniractor Datc � U � a � . . �j�;c�;na..� C�wne�s LRST �±, APPLICATION FOR SERVICES � ►U a rne u.:c� s�w y c _ 5er�ices itequested: . Improvements Permit (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing) Improvements Permit (Unrecorded Lot) Improvements Permit (Mobile Home Replace) Improvements Permit (Addition) existing Septic System Permit for New Well _ Replace Existing Well l. Permit requested by: 7. Dimensions or Proposed Structure: owner/prospective owner/agent: �, i sc-n-E Sh�eil Width: �y'.�(f.;� ddress: 38q 3 Mc -, �s N„ � 1 �d • Depth: �✓ _ - � C �� 8. What type (if any, a ditions, expansions, or replacement is anticipated to the structure or facility that this sewage disposal system is intended to serve? ome Phone #:,�9 � o� 5c�3 - 0 31S ,,,n^, � usiness Phone #: �Q►� c 2. Name and address of cunent owner: 9. Wate,r� s}�pply type: �►.,,E � �ov� private Li� public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No ❑ If so, identify location: 3. Property Description: Lot size: . Tax Map#: �l - 2 s- 5q 10. Type of structure/facility: Proposed: ❑Existing; (� Parcel#: Type of dwelling: Township: �U N►�� ►J 1��M House: � Mobile Home: ❑ Business: ❑ 5. Directions to property: State Road #& Road Type of business: S1C-;�s og CQQPi�CS d C�SS ��A ames, etc. Number of Employees: 5 �� ro cc�c�ep - c��o .�D �,e,, Number of bedrooms: 3 Q�c, HT r� �� o a Mcc, �,s u� �� Garbage Disposal? Yes ❑ No � Pass �ow� �� Ne �+� vsE o� ��c Basement? Yes ❑ No Ll If so, # of basement fixtures: 6. Number of occupants or people to be served: S CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CUx1v�x5 ur� ALL PROPOSED STRUCTURES. I hereby make application to the Person COunty Health Depai'tmetlt for a site evaluation for the on-site 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 that before an Improvements Permit can be issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of the site by the Health Dept., this application shall become void and all fees paid forfeited. igned Owner or Authorized Agent Z Permit Issued ❑ Signature Date • � ' ' Permit Denied ❑ . s � .► Plat Observed ❑ ;. ;; <': ' ': �ACI'OitS-511'H EYAi,ilAT10N . ? ;:; ' t1RPA 1 .. ' ,:: ;:' AREA 2 ;' ; ,4REA 3 I AitEA d . : _ L SLOPE (%) ... S S.. .. S � S PS PS PS PS U U U U 2. SOIL. TE7CTURE (12-36IN.) 5 S S S (SANDY, LOAMY, CLAYEY. NOTE 2:1 CLA1� . PS PS PS PS U U U U 3. SOIL, S7RUCIURE (12-361N.) S S S S (CLAYEY SOILS) PS PS PS PS U U U U 4. SOIL DEPTH (IN.) S S S S PS PS PS PS U U U U S. RESTRICTIVEHORIZONS(iN.) S S S S (�1PERVIOUS STRATA, ROCK) . PS PS PS PS U U U U 6. SOILDRA[NAG&GROUNDWA'IER S S S S (EXTERNAL R IN1'ERNAL) PS PS PS PS U U U U 7. SOII. PERMEABILTfY S S S 5 (PERCOLOATION RA7E) PS PS PS PS U U U U 8. AVAILABLE SPACE S S S S PS PS PS PS U U U U 9. SI7E CLASSIFICAl10N(SEE BELOVI� SOIL SERIES S-SUITABLE PS-PROVISIONALLYSUifABLE U-UNSUTTABLE RECOMMENDATIONS/COMMENTS: SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope patterns, etc.) C:WMIPRO�DOCSIAPPSEC.SMFINANCE.PC - C�40 t,, , PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Tax Map # ��. Parcel # Zoning To�ynship ' �t � � '� � Location/. Subdivision Name Lot# � no � �� S.R.# As Install � �� B�f��@sS �� SEWAGE SYSTEM SPECIFICATIONS Lot Area Size of Tank � Mobile Home Size of Pump Tank # of Bedrooms Nitrification Line ' � �o�.e,c� �� X ��r►� v� Max Depth Trenches Permit Void after 60 months. Permit Permits may be voided if site is al e Well and Septic Layout by if not in compliance with zoning regulations. te � � Installed by Approved ell Permit Paid ❑ WELL SYSTEM SPECIFICATIONS UbI1C ite Appro Tell Head , . � -Pu Repl pproved �" Installed by. �uired Slab Air Vent Required We We � by This report is based in part on information provided the homeowner�his/her representative in the applicatiofi 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 applicadon. Neither Person County nor the environmental health specialist warrants that the septic tank system will continue to function satisfacrorily in the future or that the water supply will remain potable. c:�amipro\permit.sam O1/95 rev.1.0