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Permit (Established/Recorded Lot) �_ Reinspection of Existing System (Loan Closing)
Improvements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
Repair/Replace existing Septic System
� rmit for New Well
_ Replace Existing Well
1. Permit requested by: 7. Dimensians or Proposed Structure:
owner/prospective owner/agent: K� PP�s Q��� K S Width: 52 �
ddress: I S25 CKtuEL C+��t� ���� n� Depth: �8�
�� QO �� 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?
omePhone#: ��n S�a-tS�G �,��
usiness Phone #: q� n S`iq -a �`-� I
. Name and address of current owner: 5 A+� C 9. Wate,r,_s,u�p ly type:
private L�public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes C" No ❑
If so, identify location: 3d' F2oM PROPeRT�; ����
3. Property Description: Lot size: ( AcRc
. Tax Map#: 10. Type of structure/facility: Proposed: �Existing: ❑
Parcel#: i�� Type of dwelling: �,�
Township: House: ❑ Mobile Home: l.� t3usiness: ❑
5. Directions to property: State Road #& Road Type of business:
ames, etc. Number of Employees: 3
0�-r Morzroa Po� AM R -u- 133� zo�Ro CeFFa Number of bedrooms:
CRosS 3�eck Nn�. «K t 33 �o-r ow Ce�F� Garbage Disposal? Yes ❑ No�
Basement? Yes ❑ No,C� If so, # of basement fixtures:
6. Number of occupants or people to be served: �
CLEARLY STAKE ALL CORNERS OF THE PROP�K'1'Y ANll'1'H� c:uxNr:x� ur ALL
PROPOSED STRUCTURES.
I hereby make application to the PersOn COunty Health Depat'tment 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.
_�
Owner or Authorized Agent
Permit Issued ❑
Permit Dei�ied Cl.,,
Plat Observed (�
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! S` nature �tiJ � Date
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(SANDY, LOAA�fY, CLAYEY, NOTE 2:1 CLA1� S S/I�/I PS PS PS
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3. SOIL STRUCTURE (12-361N.) S /� ?!. S S S
(CLAYEY SOILS) ' . S � � / :_ _ �, �;, � PS PS PS
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4. SO1L DEP7'H (INJ S S � S S
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5. RESTRICTIVEHORiZONS(IN.) S S S S
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(EX7ERNAL & LN7ERNAL) � � /p PS PS PS
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(PERCOLOATION RATE) PS � 3 A-%2 PS PS PS
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8. AVAILABLE SPACE j, [/ S S S
PS �//� PS PS PS
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9. SITECLASSIFICATION(SEEBELOW) �
SOIL SERIES
S-SUIiABLE PS-PROVISIONALLY SUITABLE U•UNSUITABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.� C:�AMIPRO�DOCSAPPSEC.SMFINANCE.PC
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PERSDN 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 # n � �o Parcel # � � 3 `
Zoning 'Township � 1Jf'1 �'1/�n���i Q�
Owner/Contractor , � D� .? — � — � � �
Location/Ad ress �
_ .
� S�� Ne.�v Dw n1f� cn /��t. S.R.
Subdivision Name ' Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area , 0 Gt.C�. Size of Tank d�% '
SFD Mobile Home� Size of Pump Tank �/�-
Business � # of Bedrooms � Nitrification Line '` C 3�
Max Depth Trenches "
Permits may be voided if site is alte
Well and Sepfic Layouf by �.
Corrv---_�_.
Date'
chan
Well Permit Paid ❑ WELL SYSTEM SPECIFICATIONS
` Individual Semi-Public Requited Slab
Public Replacement Air Vent
Site Approved � Reyuired Well Log
Well Head Approved Well Tag
Groutirig Approved `
Comments:
Date - ' Installed by o hJ Approved b
This repoa-t is based in part on information provided the hoYneowner or his/her
representative in the application submitted for this permit. The environmental
healtti specialist �is not responsible for false or misleadirig 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 tbe`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:\amip,ro\permit.sam O1/95 rev.'1.1
'. �
1'L1tSUN +�'UUN�I:'�' liNV11tUNMLN'CAL IILAL'1'If -�'�,
° WELL LOG
� . . :.
I`-q 6 �
Date:�~ . �
. . .:, -� ,�
, owner: �9�►�.�-�y � �QP�' ��L.�K S sR# ,
Location/Direetions: � � " . , `
._ , - . ' . Lot #� -. �;
Subdiv�sron Namc:
Drilling Contra�ctor: �d�tJ K�1n! E�J lLL.i An�1SO� .�.ti1G • � �
, . WELL CQNSTRUCTION ,
Distance f'rom Nearest Property Linc� Distance from Source of
Pollution - , . . _ , . 3 �
,
Total Dep.th: Ft. Yield: 2-. , GPM Static Water Level, Ft. �:�
Water Beazing Zones: L�P�th Ft. Ft. F�. Ft:
Casing: Dept}i: From � ` to� �' Ft. Diameter: � 'Inches � .
TYI'E: S:teel�: Galvanized Stee1 ✓ �
� If Steel, does owner approve: Yes � No :.. ''
Weight: ' Thickness:�_ Height Above Ground: Inches � ..
Drivc Shoe: Yes No = "
: Were f .a �
. . ;:
Problems Encountered in Setting the Casing? Yes No '�
. �;i "y es" g�ivc r���n: ,
Grou[: T. ' Neat . Sand/Cement Concrete . '. ,.. -
YPe,=: � ,
. �:
Annular Space Width �� Inches
' °� Wate'r in Annular�Space: Yes : � . No � �.� :�
IV�ett�od• Pum d, Pressure Foured ✓ .
De th: From � � tQ �� Ft. _ .
P ,.
Nlaterials Used: No. Bags Portland Cement Weight of .1 bag_lbs. .
. If mixture (sand, �avel, cuttings) - Ratio: to
ID Plates: Yes No
4 x 4�.slab= Yes�-No � ,. � ;
�r. �
DRILLING LOG .
_ . ..
De th , T.
Fram To � Formation Descri tion . ��;
�'� � ,
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I HEREBY CERT`IFY THAT THE ABOVE INFORIv1�1TION IS CORRECT AND THAT
THIS WELL WAS CQNSTRUCTED IN ACCORDANCE WITH REGULATIONS SET :
F.ORTH �Y�T�iE PERSON CnUNTY �HEALTH DEPARTMENT. � ��;
, _ �
,
. . . 3-1 �°6 .
Signature of Contrac �, ,- Date �
. : . , . ,. � �� b.
� �- �
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
y = (Void sixty (60) months from date of issuance) �� ��
DATE: �� -� 9� IlVI�'ROVEMENT PERNIIT #: D I��
TAX MAP #: PARCEL #:
OWNER/OWNER'S REPRESENTATIVE: + � '"' -�
LOCATION/ADDRESS:
S�� I �������� � � � /� � �v�,,� ��1,�
SUBDIVISION NAME:
SECTION OR BLOCK:
LOT #:
AUTHORiZATION FOR�ONSTRUCTION ISSUED BY:
AUTHORIZATION CONDITIONS
1. The Wastewater system construction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Permit #[3 U/� 7. The
construction and installation must also meet all applicable rules and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any alterations in site or soil conditions (including structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authorization and associated permits.
4. Conditions:
Person Requesting: