A25 7C�. 12-27-1995 02�13PM
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FROM PERSON COUNTY HEALTH DEPA TO
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19196826580 P.62
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� Improvements Pernut (Fstablished/Recorded Lot) _ Reinspection of Bxisting System (Loan
_ Improvemcnts Permit (Unrecordcd Lot) Repair/Replace existin Septic System
Improvements Permit (Mbbile Home RepIace) Permit for N w V�ell i
_. �mprovements Permit (Addition) . Replace Existing Well' � %
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` Baeteria ` Chemical �, Petroleum _ Pesticide
1. Permit requested by:
owner/prospective owner/agen •t. i�rpr�
Address: �I i� 3 t��c h'-� t�
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� ome Phone #: (q��'�3i- (�Stir1
¢ vsiness Phone #:_ �A14 �(n-f��� I
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.. Nam� and address qf cunent o�vner:
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Descn
'19c G�i�r s M:
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Lot size: �s
Clos
Lead
7. Dimensions or Proposed Structure:
Width: � 4 ' � �
Depth: 3 2 ' j
8. What type (if a�y, d�iEions, expansions, or
replacement is a�tt�cip te�l to the struct re or faci ty
that this se�age isposal system is in nded to s ve?
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9. Water sup�,ly tSpe:
��2 • private C�Y public ❑ comn
�/� • Are any wells on adjoining
��-3 If so, identify location:
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Tax Map#: � �1 a � �
Parcel#: '7 �
Township: U hn �h S�9w�
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Directions to property: State Road #& Road
mes, etc. ,
1 cGhe t's rn� i I�d . b�u s+ ali st- • iYlunda
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I0. Type of structureJfacility:�roposed: Q(Exist'�hg: C]
Type of dwell'ng: � �
House: �Mobile Home: ❑ Business: ❑
Type of business: '
Number of Employees:
Number of bedrooms: -3
I o-F es id� 3 �� hu�s�. o e'f t wh;' ; Garbage Disposal? Yes � No ❑
�!j2fq,I0� �• �0.t7�,� ha�st . �q�.� ►'Y�cGl,�ti�f m; n Basement? YesO NoC�'If so, # f b�sement fixtures:
6. Number of occupants or people to be served: 3 ,
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS F ALL
P1tOPOSED STRUCTURES.
I hereby make application to the PersOn COIIIIty $eSlth DepSttment for a site evaluatin for the o�-site j
�sewage disposal system for the above described praperty. I agree that the contents of this application are tr�e f
and represent the inaximum facilities to be placed on the property. I understand if the site is aItered. or the! �
� intended use changes, the permit shalI become invalid. I understand that before an Improveme�ts P.ermit�an b a
issued, I must present a survey plat of the property to the Health Dept. I understand th.at in th� event•I have not
delivered a survey plat of the propecty to the Health Dept. within 60 DAYS after the date of the evaluation jf
the site by the Health Depk, this application shall become void and all fees paid forfeited.
Signed Owner or Authorized Agent
TOTAL P.
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
���location Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map #_� �� Parcel # �% C
Zoning Township . �inh,'nc �.-n
Owner/Contractor Dat�✓e�
Location/Address S�-# /?�3 �
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S:R.# �� � �
Subdivision Name Lot# /vl C GeQ s/��: /��v4 �
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area , p�Gvc Size of Tank � o n
SFD Mobile Home Size of Pump Tank
Business # of Bedrooms�_ Nitrification Line �p0 x 3`
Max Depth Trenches �[� " _
Permits may be voided if site is altered or '
Well and Septic Layout by
Comments:
Date
ell Permit Paid
3ividual__�
Installed by
�e Approved
ell Head Approved
�outing Approved_
Comments:
�d se ct nged.
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�_Approved by
WELL SYSTEM SPECIFICATIONS
Semi-Public Required Slab
Replacement Air Vent
_� ' Required Well Log
Well Tag ,
Date .�-.30 -�f Installed by ''��,�� ���Yn� �� � 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 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 ia the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
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Lester H. �avis
D. B. 141-294
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PERSON COUNTY ENVIRONMENTAL HEALTH
WELL- LOG, _- : _._._ _ -� :._ _ _
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Date: -a � '
• Owner: + � �
Location/Directions:
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SR# 133� �
Subdivision N�une: Lot #
Drilling Contractor: �:�-��% ���z`�-� �
. � WELL CONSTRUCTION
Distance from Nearest Properry Line �(� f�-r- Distance from Source of
Pollution /.Cst,� � � �
Total Dep.th: �3c� Ft. Yield: � GPM Static Water Level o Ft.
Water Bearing Zones: Depth �-�Ft. F� F� Ft.
Casing: Depth: From G' to �/� Ft. Diameter: �� Inches
TYPE: Steel � Galvanized Steel —
If Steel, does owner approve: Y�s No
Weight: Thickness:_� Height Above Ground: ��I Inches
Drive Shoe: Yes ,i- No
Were Problems Encountered in Setting the Casing?. Yes No ,�-
If "yes" give rcason:
Grout: Type: Neat SandJCement Concrete
Annular Space Wid[h Inches
Water in Annular Space: Yes No
_ .. Method: Pwnped . Pressure � Fouied � - -
Depth: Fr�m � � �o a� Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag lbs.
If mixture (sand, gravel; cuttinas) - Ratio: to
ID Plates: Yes � No � - � �
4 x 4 slab Yes No
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I HEREBY CERTIFY THAT THE ABOVE INFORMr�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED 1N ACCORDA�'�tCE WITH REGULATIONS SET
FORTH BY�THE PERSON COUi�1TY HEALTH DEPARTMENT.
Signature of Contractor Dat�
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