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Size of tank:
T e District� h Department
range, Person,�C�swell, C�aiham, Lee Couniies
� Water Supply and Sewage Disposal
IMPROVEMENTS PER IT No.
• Date�.� � �—
Owner: �,�jL.��u t� ��^�f/�(r�
Location:
- '�`�P � �P ���/^'�,�
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Contractor: �
Water Supply: Private %� Public
Facilities: No. bedrooms � Dishwasher,�bisposal,
� _
Other disposal facility:
� appliances /
Nitrification line:
_ e � !"�,. , _ . 1
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVED BY A MEMBEft OF THE DISTRICT HEALTH DEPAR.TMENT
STAFF BEFORE ANY POftTION OF THE IN LLATION IS COV-
ERED AND PUT INTO USE.
Date approved: Signe
We1L• � S itarian
Sewage Disposal: _ I Counter-
BY: signed
(Owner or his representative)
Ceztificafe of Comple2ion
�, � �
Date Approved. By� 4
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(OVER)
Location of well and sewage disposal facilities sketched on back.
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on� lot. Write in measurements in order that installations may be located
a; later date. Note location of water supplies on .'adjacent lots.
(1J ' (2)
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Improvements Permi[. (EstablishedlRecorded Lot) _. Reinspection of Existing System (Loan Closing)
ImpFovements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
Im rovements Permit (Mobile Home Replace) _ Permit for New Weil
mprovements Permit (Addition) _ Replace Existing Well
_
" f�T ° k"�_ � `'Y 1�ater SamPle �o be Collecter'1�
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Bacteria Chemical Petroleum . _... Pesticide _ Lead
1. Permit requested by: .
owner/prospective owner/agent: ���'sfp��•� C�/��1;
Address: t�d i� n'? c r��- * nt �' I/ , f�'� •
rn.,,::��� �'U, !' �.����
ome Phone #:Sg 7" g-�•2r�
usiness Phone #: _ -
Name and addre:
l� r�-�•t�'���'.� e� r
�J7'cl i 7�.
Ca.►-�n r� 1
. Dimensions or Proposed Structure:
Vidth: z � �G O M
,A„rti. ao
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?
_ , . .q �.
current owner: . Water supply type:
p �). � � ,�/,;,/�,� t�,��J�, private ��public ❑ community ❑ spring ❑
. jy?, �� j,�'�/ _ Are any wells on adjoining property?Yes ❑ No p.
� ,,,� ,� rt� If so, identify location:
. PropertyDescription: Lotsize: 1 A-�- •
- __ __.. --.._ _ __
Tax Map#: . �2 � _ : . , . .
. Parcel#: . � 5
Township: _ C�: r.� -� _ . _ _
�. i Directions to property: S ate Road #& Road
James, tc... . _ �- ---- ; _ _ .
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0: T e of structure/facility: Proposed: C]Existing: Q---
___..YP , _ __.._.__ ._. � ,
_ _ _ _ _.
'ype of dwelling:
House; �'Mobile Home: C� Business: D
Cype of tiusiness: �
lumber of Employees: _._
_: ,
vumber ,of bedrooms: .�_
3arbage Disposal? Yes ❑ No L�i"' -- ---- - -- -- -
_ Basement? Yes ❑ No�'I`f so, # of basemenf fixtures: �
6.� Number of occupants or people to be served: � �'�"' '
i CLEARLY STAKE ALL CORNERS OF;THE PROPERTY AND THE CORNERS OF. . ALL `,.
_ _. . , ----.---_ _ -.-- ---. - -- �; _ _ PROP03ED_STRUCTURES. --
. _ _._- __ __--_ __.__ --- -
I hereby make application to the PersOn County Health Department for a site evaluation for the on-site ,
�_-__.- � .- -'
sewage disposal system for the above describedpcoperty. I agree that�the-contents of this application_are true
and re resent the maximum facilities to be placed on the property. I understand if the site is altered o'r the =�-
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intended use changes, the permif sha1l become invalid: I understand that before an Improvements Permitcan be
, issued; I must present a survey plat of the property to the Health Dept._ I understand that in the event I have not
del�vered a survey plat of the property_to the Health Dept. within .60 DAYS after the date of the evaluation of
the-siteby the Health Dept., this application shall become void_and all�fees.paid forfetted �- _ ,
.
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Signe� Owner or Auth zed Agent; ; � ..� -
Permit Issued ❑
Permit Denied ❑
Plat Observed ❑
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Signature
Date
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KECOMMENDATI ONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
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areas, welis, water bodies, slope patterns, etc.� �� 1 � ;'. (� ;' . ` C:MMtPRUDOCSAPPSEC.SMFWANCEPC
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIl'ROVEMENT 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 cons�.�uc��io:i
has been issued.
Tax Map # � �J� Parcel # w�
Zoning Township v i rr �i
Owner/Contractor P� w� Da e g- J— G% �
Location/Address 336 � �1� // �
S.R.# /33 G
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
r---- as re
0
0
Lot Area Size of Tank
Mobile Home Size of Pump Tank w�,�
# of Bedrooms Nitrification Line 1�j� ,'s- n�
„� �� f,� J�,,, ,,,,� g� jp,.k M� Depth Trenches
Permits may be voided if site is altered in nd d use hanged.
Well and Septic Layout by
Comments:
Date
�Well Permit Paid ❑ WELL SYSTEM SPECIFICATIONS �
Public
Site A
Well �
Date
Semi
Installed by.
�equired Slab
Air Vent
Requ' d Well
1 Tag _
Approved by
This report is based in part on informatioa 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 atso 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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LEGEND
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property of ..
TpPHER CRA1�
CHRIS
Cunningh ., son Gb., N G
phi//ip ✓ H° �S �
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Sco/e /"= 500,
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���CIP l•�..•� �.,,�N��pu ,
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�� phNllp .!. Hall, ce�t'�N �t under m)
and �uPerylsfon thk MaP was drawn fron
tleld survey Pe
rtormed bY R1e• and that
�� � a o 0 0 . w��ss my na
�s Z daY � �.` �— ^�— a --19 �� ""j
Sworr�to and subscribed before �'►
, � J� 19J� NotarY P
�y oommission exPire� 1 o F E 8� i.�9