A26 154�
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Improvements Permit. (Established/Recorded Lot) ._ Reinspection of Existing System (Loan Closing)
`�ImpFovements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) _ Permit for New Well
Improvements Permit (Addition) _ Replace Existing Well
1. Permit requested by: .
�wner/prospective ow ec
Address: � - !
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me Phone #:
siness Phone #• �i 10 � . �7S�h�f
Name
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Tax Ma�
Parcel#:
7. Dimensions or Proposed Structure:
Width: _-
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?
of current owner: '`��C 9. Water supply t}pe:
t private �public ❑ community ❑ spring ❑
--- Are any wells on adjoining property?Yes ❑ No �
If so, identify location:
. Lot size:
. Directions to property: State Road #& Road
iames;�tc.
10. Type of structure/facility: Proposed: DExisting: Q I
Type of dw�ing:
House: Mobile Home: C� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �_
Garbage Disposal? Yes ❑ No �
Basement? Yes ❑ No� If so, # of basement fix[ures:
� Number of occupants or people to be served: �_� _ �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PerSOII COunty Health Department 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 [he 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 plac of the property t the Health Dept. ithi 60 DAYS after the date of the evaluation of
the site by the Health Dept., this app�ion shal'1 become �oi�d all fees paid forfeited.
Si�neci Owner or Authorized Agent
Permit Issued Ll�'
Permit Denied ❑
Plat Observed �
I. SLOPE (96) '
Signature Date
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SOII.IFJC7IJRE ( � 2-36 tN.)
1NDY, LOAMY. CLAYE1f. NOTE 2:1 CCAI�
SOtI. S77tUCTURE (12•36 (N.)
IAYEY SOiLS)
SOIL DEPTH (IN.)
RESTRICTiVE HORI7ANS (INJ
fPERViOUS STRATA. ROCK)
SOIL DRAINAGFIGROUNDW'A7ER
K[ERNAL & iNTERNAL)
son eeR►.+ena►urr
ERCOLOA710N RA7"E)
AVAIL\B[E SPACE
SITE CLASS[FICAT70N(SEE B ELOW )
itL SERIES
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S-SUITADLE PSPROVISIONALLYSURA6LE U•UNSULTABLE
RECOMMENDATIONS/COMMENTS:
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SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, eIC.� C:WM[PRO�DOCS�P.PPSEC.ST7FWANCE.PC
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B 1222
: � � PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION INIPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Rel,ocation Activity shall be issued until Authorization for waste water system construction
� has b�en issued.
Tax vlap # A ,� �p Parcel # � �
Zoning Township
Owner/Contractor� �,�f ," I �,' , M inJ �%e r s`Tr, � Gi h �.ti., Date �-„� �_ 9(o
Location/Address �� � o✓,� �-fu �/ i� _� � L� n�� c� S,n� l30 9 0�� /rFt�:
Subdivision Name
�r
�
Lot#
S.R.# 5 7N�
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area �.-c Size of Tank %�% ��ti �
SFD Mobile Home Size of Pump Tank iv l�
Business # of Bedrooms_�_ Nitrification Line� 17/� �,�3
Max Depth Trenches � � ��
Permits may be voided if site is altered or i
Well and Septic Layout by
Comments:
ch
Date _ Installed by -� � ��, ,� � c., Approved by.
Well Permit Paid WELL SYSTEM SPECIFICATIONS
ublic
ite Approved��
�ell Head Approved
�routing Approved_
Comments:
Semi-Public Required Slab _
t�acement Air Vent
Required Well Log
� Well Tag
Date � - / - � � Installed by.
Approved by.
This report is based in part on info�mation provided the homeowner or Kis/her
represe�tative in the application submitted for this permit. The e�vironmental
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. Neii:her 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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i. WAGSTAFF
: AL.
'4, P. 257
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1.08 ACRES
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"THE MEADOWLANDS"
PHASE 1
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I.'1?RSON C��IIi;'I'Y I�;iVV I.KONP;::N'L'i�l, IIliA[.'1't1
Da te: �a :
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Owner: _ , , f _ G,� ,�
yl:ocation�irections: -�Z,,_�,__,S"-'�'
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Dz-illing Contractor: --�'�� �-�? u W'�L/� �,
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tiVl;l ,f . c '( )N�'I'IZUCI'1ON ;
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Distance from Ncarest I'��o �crt Lii►�: ' � �� �°
1 Y . 1.�_,_�/�_� llis�anc� from Source of ' ';i�
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Pollution , � g .
Total D � th•. "``�
...�p. •�.2o Ft. Yicl�:_�V_ ____ CJ1'M Static WaterLeve '
Water Bearing Zoncs: ,� I:t. �.�, r-�. 1 �Fc. .. :;;
Depth �__,�____.___ / _[=t. ��t. .:s�
Casing: Depth: Fi-om �� �o �, �----�'t- Di�unc�c 6� � Tnc e �1��4
--_ r: h S �.
TYPE: Steel _.t:T.i(v;�nizci1Stccl � . � � ��>;;�
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If Steel, does owncr approv�:: },'�;; No �. `�'
� Weight:�,�3 Thickncs:�:---�j_�_.�-�cight Abovc Ground � ����
:- ,�,� Inches ` -,M
Drive Shoc: Ycs t% Nc� �: `�:
Were Problems Encotintercci iri Scltii��; tlie Casin�;'1 Xes_ No � `����ya
IC "yes" give reasoii: , ::=�:�;
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Grout: Typc: Ne�it 5:111(I�(;CI11C11L ~�� . , ' •' • "f�Y>=.
Concrete � ;;,��
Annular. Spacc W�it�� .3 lilchcs � '.:.
Water in .E1.nnular Spacc: Xc��__�__----- N° �-- � '�����
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Method: ' ��
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Materials Usccl: No. I3a�;s !'c,� tl.iricl Cciilcnt____�__ Wcit;}i[ of .l ba�_lbs:����:•;!';�;��
If mixturc (sand, grrivcl, cuttir��;�:) �- R.itio:_
ID Plates: Yes ✓ No --�-- tc> A , : . : . ::,,.�
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X HEREBY CERTIFX THAT TI-IE AT3OVL 1NFORMATION IS CORRECT AND TH;
T�S WELL WAS CONSTRUCTEI) IN ACCORDA.NCE WITI-I REGULATIONS��S'
FORTH �3Y.THE PERSON Cni1NZ'�' [I!-;AI,'I'[I DE1'ARTML'•N`1'. �
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�]S�I1:lIUCC O(� (~OillrlClOC
Datc
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AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: �-.2 ? �'1 � IlVIPROVEMENT PERMIT #: IZ2 2
TA � P✓IAP #: � PARCEL #: 5
OWNER/OWNER'S REPRESENTATIVE: %� �, �I �� L✓li�PYf Tr. � G'%•��.
LOCATION/ADDRESS:
s�%� �
s�.�- c�a �
SUBDIVISION NAME:
SECTION OR BLOCK:
W ��i,,. c�s s�%� LOT #:
�ti, /
AUTHORIZATION FOR CONSTRUCTION ISSUED BY:
AUTHORIZATION CONDITIONS
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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 #�� 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: