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Amount paid i-:t�x�v"��, �.i:, ci57''3, p �a °2'�6 �
Receipt 4� �o�r�er�Q2-33-15 ��Mf� Date
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fmprovements Permit.(Established/Recorded Lot)
Imt�ovements Permit (Unrecorded Loi)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
Reinspection of Existing System (Loan Closing)
_ Repair/Replace existing Septic System
Permit for New Well
_ Replace Existing Well
1. Permit requested by: . � %� � �/,, / 7. Dimensions or Proposed Structure:
owner/pros ective� ner/agent: � fl/� /�"d � Width: �
Address: li U U _ Dep[h:
- 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?
Home Phone #: �Cf.�f � l�D
usiness Phone #: �'�'i �f- 7 � �v
2. Name and addre5s of,curren[ owner: 9. Water supply type:
� private f�public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No p.
If so, identify location:
3. Property Description: Lot size: �'� 3 �
�. Tax Map#: L� 10. Type of structure/facility: Proposed: �Existing: Q
'� Parcel#: -tk� do�� Type of dwelling:
I Township: �? .�. /���` o-+�� House: C�Mobile Home: C] Business: ❑
a5. Directions to property: State Road #& Road Type of business:
� Number of Employees:
ames,�tc.
� ,� /jl � � �S � Number of bedrooms: �— �
� Garbage Disposal? Yes No
�"' Basement? Yes ❑ No If so, # of basement fixtures:
I6. Number of occupants or people to be served:
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CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pet'SOn COunty Health Depal'tment for a site evaluation for the on-site
se�vage disposal system for the above described property. I agree that the conten[s 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 [he property to the Health Dept. I understand that in the even[ I have not
delivered a survey plat of the propert to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this a licati¢njshall b�co�i void and all fees paid forfeited.
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Signcei Owner or Authorized Agent
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT
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 # �" �o Parcel #
Zoning Township
Owner/Contractor
Location/Address
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Date 2 ZZ
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Subdivision Name Lot# �f
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area� I
SFD l / Mobile Home_
Business # of Bedrooms
Size of Tank��
Size of Pump Tank_
Nitrification Line -
Max Depth Trenches
Permits may be voided if site ' alte or inte ded e hanged
Well and Septi Layout by
Comments:
Date - - Installed by , Approved
Well Permit Paid WELL SYSTEM SPECIFICATIONS
Semi-Public
Site Approved �/ y
Well Head Approved '
Grouting Approved �/�
Comments: �n o �
9
Required Slab
Air Vent �
� Required Well
)'G� Well Tag �
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Date ' � C� Installed by ��lans W�e�,� Co Approved
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This report is based in part on information provided the homeowner or his/her
represeatative 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 in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
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DEEDS OFFIC£ IN BOOK PAGE
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SPACES TO PUBUC OF PRIYATE USE AS MOTED.
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S1�OIVISION RE6ULATION JUR:SDIC7ION OF _ _ _ _ _
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