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Amount paid a�d•
Receipt l� � • dQ �
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.✓—:..-' "_'....:................._---_."
Improvements Permi[. (Established/Recorded Lot) _ Reinspection oF Existing System (Loan Closing)
Improvements Permie (Unrecorded Lot) _. RepaidReplace existing Sepcic System
Impcovements Permit (Mobile Home Replace) ,_ Permi[ for New Well
_ Improvements Permi[ (Addition) _. Replace Existing WeII
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l. Pecmit requested by: .
ownec/prospective ownec/a��.�} t:
Address: �--�I.l vJ�-` �d �� �S
�. P�0 � [3cx _8i�
,. vt,,.� � 1.0 [' � 75"I �
ome Phone �: ��`� �s�� �
usiness Phone #: -
7. Dimension$ or Proposed Structuce:
Width: _— 13�d S�- ��'�
Depth:
8. What type (if any, additions, expansions, or
replacement is anticipated [o the structure or tacility
thac this se�vage disposal system is intended to serve?
Name and addreSs of,current owner: 9. Water supply type:
• � � P _ private �. ublic ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No [�.
If so, identify location:
. Property Description: L.at size:
. Tax Map#: � 2—
Parcel#: � , � � [d��
Townshio: f� I.� VC.. � �
. Direc[ions to propecty: State Road #& Road
dames,� c. ��r� �a — � ��
� raoi�s
bo, 1 a -
10. Tyge of structurelfacility: Proposed: �xisting: Q
Type of dw�e,l�li g:
House: IQ Mobile Home: Q Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �—
Garbage Disposal? Yes No �l
Basement? Yes ❑ No1�'rso, # oE basement fixtures:
�6 I�Iumber of occupants or people to be secved: �-
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AI�ID THE CORNERS OF ALL
PROPOSED STRUCTURES. .
I hereby make application to the PersOn COunty T�ealth Department for a site evaluation for the on-site
sewage disposal system for ihe above dese�ibed 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 ptat of the propeRy to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Hcalth Dept., this�plicatioa shall become void and all fees paid forfeited.
.
Sig�(�vner or Authorized Agent
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B 2824
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 # ,�t �� Parcel # � � �
Zoning Township D! � J 2.. (-� � 1)
Owner/Contractor L; S e Date 3�ZU -g 9
Location/Address S7 nl T�L K� �C� r.r � l—c�� �� on ✓t eXf- fo
Subdivision Name
S.R.#
Lot# Z
SEWAGE SYSTEM SPECIFICATIONS
pair Lot Area `j .$�}
D �/ Mobile Home
siness # of Bedrooms �
Size of Tank 1�
Size of Pump Tank_
Nitrification Line�
Max Depth Trenches
Permits may be voided if site is altered or intended use
Well and Septic,,.�,ayout by
C:nmmentc� \���'�� r7Y1C� , �r J� . Se�
Date �--'�
Permit Paid ❑
te Approved
ell Head Approved
routing Approved�
Comments:
rte�s►7��-� ���J'ra�.—�.Ilt�7�•lt�.
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WELL SYSTEM SPECIFICATIONS
Semi-Public Required Slab
Replacement Air Vent ✓
Required Well Log —v�
Well Tag �/
� 7'�'�' Sa�tC�C�' ✓
�. - �, �� � � -� � �I � '�����.� ! I • �� • -� �
This report is based in part on i�formation 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 aor the environmeotal 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 Ol/95 rev.l.l
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DATA TABLE � , '� , ,ACRES'
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LEG BEARING DIST. : �\S ��0�.., Ro ;
1:' ` N62•05' 31 "w 57. 82' F' tO
S: �
'2 N58'32'S1"w 62.42' - ''
3 � N54'46' 15'M 61.53' , `� `:. NF � � cr.v . ..,'
�' 4 �: ` N52'24' �5"M 62. 28' ` ` . � � N
'.5 N54'26'�f5"w 63.39' �
6 ''NSO'28'�5•w 70.01' � �`�NF :
' �'7 520`40' 17"M 50.00' _ - .
`+ . •
Date:
Owner. �
Location/Directions:
Subdivision Name:
Drilling Contractor:
_. _. ...._ _._._ . . .._ .
PERSON COUNTY ENVIItOPiMENTAL HEALTH
WELL LOG
.. __ . _._.. �la�...�
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Lot #
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. WELL CONSTRUCTIO'N --
Distance from Nearest Property Line Distance from Source of
Pollution � ''
Total Dep.th:_��_ Ft. Yield:�_ GPM Static Water Level `� Ft.
Water $earing Zones: D�epth�b Ft.�_Ft� � F�_��.
Casing: Depth: From p to�_Ft. Diameter: Inches
TYPE: Steel - Galvanized Steel .�
If Steel, does owner approve: Y�s No
" Weight�: � Thickness: l� Height�Above Ground: 6�% Inches
Drive Shoe: Yes ✓ No � :
Were Problems Encountered in Setting the Casing? Yes No � �
II' "yes" give r�ason:
Grout: Type: Neat Sand/Cement_ ,/ Coricrete
Annular. Space Vi�idth Inches
Water in A.nnular Space; Yes No
_ .. Method: Pumped . _ . �Pressure � � Poured ✓ ��- �. . . •: - :.
Depth: From O to ��� Ft. � �
Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs.
If mixtuie (sand, gravel; cuttin�s) - Ratio: to
�ID Plates: Yes ✓� No � � � •�" .
'� 4 x 4 slab Ye.s�—No �
I HEREBY CERTIFY THAT THE ABOVE 1NFORMATION IS CORRECT AND THAT
T�S WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH gy.THE PERSO�t C�Ui�'I'y HEALTH DEPARTMENT. �
� � �---
�Signature of Contractor ace
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