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Amoun�t paid
Receipt /i
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3-�a-q 9
Date
Improvements Permit-(Established/Recorded Lot) I_ Reinspection of Existing System (Loan Closing)
ImpFovements Permit (Unrecocded Lot)
� Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
Repair/Repiace existing Septic System
Permit for New Wel(
_ Replace Existing Well
l. Pecmit requested by: . 7. Dimensions or Proposed Structure:
owner/prospective owner/age t: Width: ��,�.� S� ��-,
Address: . �--►1�1 vJ� a� �o �eS Depth:
•. P` 0' ��x - g S 8. What type (if any, additions, expansions, or
� a� � 3 ceplacement is anticipated to the structure or facili[y
�� _,7.s that this se�vage disposal system is intended to serve?
Home Phone #:
usiness Phone #: �
2. Name and address of current owner: 9. Water supply [}'pe:
� priva[e .�ublic ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No [�.
If so, identify location:
3. Property Description: Lot size:
. Tax Map#: � �,�, L+ 10. Type of structurelfacility: Proposed: xisting: Q
Parcel#: � �� ��, ype of dwelli g:
Townshin: _� l.� V_C.. i i House: Mobile Home: Q Business: ❑
5. Directions to property: State Road #& Road Type of business:
ames,� c. Number of Employees:
��p�5 ��r� �a - 1 n�� Number of bedrooms: �—
bo. 1 a _ Garbage Disposal? Yes No �
Basement? Yes ❑ No�'�so, # of basement fixtures:
6. Number of occupants or people to be served:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS 4F ALL
PROPOSED STRUCTURES.
I hereby make application to the Pet'SOn COunty Iiealth Department for a site evaluation for the on-site
sewage disposal system for the above desccibed property. I agree that ttle contents of this application are tcue
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 Pecmit 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 propecty to the Health Dept. wiehin 60 DAYS aftec the date of the evaluation of
the site by the Health Dept., this�plication shall become void and all fees paid forfeited.
Sig�icc� (�ner or Authorized Agent
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PERSON 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 #_� �-� Parcel # � �D �
Zoning Township �; �� I..4�,1
Owner/Contractor �,- ,, ,,, � nnn0 3one=� Date �-- Z}4-49
Location/Address
Subdivision Name
Lot#
S.R.#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area �� ZI �4-G Size of Tank �nQ�c��Q, +�,�„c.Q.a.�o �; i-�-u
SFD i/ Mobile Home Size of Pump Tank �— _
Business # of Bedrooms 3 Nitrification Line 6I>'}C3 '
Max Depth Trenches �� «
Permits may be voided if
Well and Septic�L,.ayout by_
Date
�ESCI� 4��JL 1
altered or inte�,ded use changed.
,��-�- � ��Approved by GJ�� �-�-�-
Well Permit Paid ❑ WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab
Public Replacement Air Vent
Site Approved Required Well Log
Well Head Approved Well Tag
Grouting Approved Z a N"I -�3- 99
• . ,.�� • L� .. .. � !:1,�'� �► '.�%�''
Date Installed by Approved by
This report is based in part on information 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 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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Owner. �
Location/Directio�
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PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG '
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SR# ' � � .
Subdivision �Name: __ Lot #
Drilling Con�-actor: („� . �
Distance from Nearest Property Line �(� Distance from Source of
Pollution_ (.C� O '
Total Dep.th:�_1Cc�'� Ft. Yield:� GPM Static Water Level Ft.
Water Bearing Zones: D�epth 1�� FL��_F� � Ft� ��,
Casing: Depth: From �3 to�_Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel _�
If Steel, does owner approve: Y�s No
� Weight�: � Thickness: /F� HeightAbove Ground: 6�� Inches
Drive Shoe: Yes ✓ No
Were Problems Encountered in Setting the Casing? Yes No �
IF "yes" give r�ason:
Grout: Type: Neat Sand/Cement ,/ Coricrete
Annular. Space Width Inches
Water in Annular Space: Yes No
- -. Method: Pumped . .. . �Pr:ssure � � Poured_t/ �� -. . . . •, _ ..
Depth: From O to �, � Ft. . •
Materials Used: No. Bags Portland Cement Weight of .1 bag lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
�ID Plates: Yes ✓ No ' � � •-' .
�� 4 x 4 slab Yes�—No �
:
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I HEREBY CERTTFY THAT THE ABOVE INFORMr�TION IS CORRECT AND THAT
T�S WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH By�THE PERSOv C�UiJ'I'X HEALTH DEPARTMENT. �
✓ 22
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�Signature of Con�ractor D� �
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