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` a PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMI'ROVEMENT 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 # � Z �O Parcel # � 1 O
Zoning Township �(; V�. � �
Owner/Contractor L;n o s Date 5 ZD' 99
Location/Address S��N � S '� `�� O'"� � � `�"
S.R.#
Subdivision Name � � 5 Lot# r%
SEWAGE SYSTEM SPECIFICATIONS
Lot Area .�/4G Size of Tank %��
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SFD ✓ Mobile Home
Business # of Bedrooms�_
Permits may be voided if s
Well and Septi Layout by_
,
Comments:
Installed
or
Size of Pump T�
Nitrification Line �(�j'
Max Depth Trenches�
�Z' �E �fo -�VG �
pded use changed.
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L ��. � • � � • - � � ���
ell Permit Paid G�' WELL SYSTEM
vidual 1/ Semi-Public
lic Replacement
Site Approved
Well Head Approved �/
Grouting Approv�ed SjJ tE '1 a3-�R _
Comments:
TIONS
Required Slab �/
Air Vent �
Required Well Log ✓
Well Tag ✓
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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 e�vironmental 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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Amount paid �'1�- �
Receipt d � �20
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Improver,lents P�rmi�• (�stablished/Recorded Lot)
In�orovcmcncs Pcrmic (Unrccordcd Lot)
Im�rovemcnts Pcrmic (Mobilc Home Replace)
et�: � =i� -
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Date
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Reinspe�tiar, of cxisting System (Loan Closing)
Reoair/Rtalacc existing Septic Systcm
Pc: mit for Ncw Wc'.l
Impcovemeats Permic (Addition) I Re�lace E.:is:in�'Nell
I. P�.:r.it re�aeste� by: .
c�.vn�:/pros�e^'ive �wne:'��P�
Accress: � C'- 13C2yCy
v.. Phor,e . '� 3 S� -✓-`�-
� Hom.� �:,.
� �siness ?hone �:
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7. Di-�ensions er P:c�esed Str�:cture:
� Wid::^.• �.s�—
_ DeocZ: 33
8. W:at tyoz �ii any, accitions, expansions, cr
reaiac�:nent s �^':c:. �:-� to the structure ar :�c;lity
thac c::is se•.va�� L:s; ���'• syste,;i is intea�e� :e serve?
� 9. Wacer suo^ , :;'�e:
. ti ame and addreSs of c�.::: enc owne::
• ' priva;e . p�o:ic'� coramunity ❑ sprin; C
Are any wei!s c<< adicinin; orope^y?Yes ❑�to �
If so, idenciiy lccatioc::
3. Property Desc:iocion: Loc size: / ��N
4. Tax Ma�: �-' � 7�
Pa:celz: 7/ 7' f� �
Townshio: f3 �.I Yi� �1 �/�
5. Direccions to property: Scate Road n& Road
1�Iames.stc.
I0. Type of scr,:c:�sr���2ciiity: Proposed: Q�Existing: .C-'s
Tyce o[ dwe;li^�: ,
House: [T-�i iobile �:ome: C� B usir.ess: ❑ i
Tyge of business: �(
Number of Er►ptoyees: ;
Number of bedrooms: � '
Garba�e Disposal? Yes ��0 '
Baser.zent? Yes ❑ I10 it�Fso, � oE baseme:►c fixtures: �
t 1_
6 I�Iumber oi occuoancs or peop�e io oe servca
CLEARLY STAiLE ALL CORI�IERS OF THE PROPERTY AND THE CORrIERS OF ALL
PROPOSED STRUCTURES. -
I hcrcby makc application to thc Pet'SOn COunty Health Department fvr a sitc cvaluation foc the on-site
scwage disposal systcm far the above described property. I agrcc that ttie concencs of this application arc true
and represent the maximum facilitics to be placed on the propecty. I understand if the site is altered or the
intended use changes� the permit shaII become invalid. I understand that before an Improvements Pcrmit can be
issued, I must present a survey plat of the propecty to the Health Dept. I undecstand that in the event I have not
delivered a sucvcy plat of the property to the Hcalth Dept. wichin 60 D�YS after chc date of thc cvatuation oE
the site by the Hcalth Dcpt., this application shall bccome void and all fccs paid forfcitcd.
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c AuttioriZcd Agcnl
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PERSON COUNTY HEALTH DEPARTMENT
SUBSUR�ACE WASTE�IVATER SYSTE1V,i NdOIeTITORING REPORT
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Date of Inspection
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Fr-2�—[qQ9
System Installation Date
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Property
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Type Tax Map Pazcel #
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Instrucrions: Check yes or no for appropriate items and explain inspace provided for remarks and
comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaivated, indicate
hy "N" and explain. Nota that this monitoring form is not totally inclusive for all systems. All mai,7tenance
and monitoring items specified in the permit are to be carried out.
INSPECTION RE3ULTS
�OLLECTION SYSTEM:
Evidence of leaks ?
Tank risers accessible, free of
infilttation and surface water diverted ?
Septic tank needs pu �ing ?
�nches of solids: 1 �
Septic tank filter cleaned 4
F,FFLUENT DOSING SYSTFM:
Required pumps present & functional ?
High water alarm operating proparly ?
Floats, valves, etc. in good condition ?
Cantro! panel & components in good
condition 7
Effluent free of excoss solids ? � �
Inehes of sblids(pump/�ose t•): � 3
Elapsed time readings 7
Counter readings ? vt
Drawdown rate: O
YES / NO
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DISPOSAL FIELD:
Evidence of effluent surfacing 7 ❑
Evidence of eftluent ponding in trenches ?❑
Surface a�ater e�ectively diverted ? '�
Di��rrsioaslsw3les propesly mai.�tainPd 7 �
Vegetative cover maintained ?
Protected from trafuc/unauth�rized uses ? �
Distribution devices in good con.dition ?�
Field free of sett(ed or Iow azeas ?
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PRESSURE DISTRIBUTION SYSTENI:
Tumups/cleanouts/valves/taps intact &
accessible 7 ❑ � ❑ � �q
Fressure head properly adjusted ? ❑ I❑�C(�
COMPLIANCE:
Compliant �-
Non-compliant ❑
Nee3s Maint�n�.nce '�
A,UDiTiONAi. CONL�ivTS: �aivt ��"` � �
REMARKS
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Date: `i '
Owner. . � . f .�c c
Location/Directions: _
Subdivision Name:
Drilling Con�ractor:
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Distance from Nearest Properry Line [O Distance from Source of
Pollution . f bC� '
Total Dep.th:. ( l� Ft. Yield:� GPM Static Water Level Ft.
--t---
Water Bearing Zones: D�epth �_FL � F[. � F� ��,
Casing: Depth: From � to�_Ft. Diameter: Inches
TYPE: Steel - Galvanized Steel �
If Steel, does owner approve: Yes No
� Weight: � Thickness: !� HeighrAbove Ground: ��i 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
Arulular. Space Width Inches
Water in Amiular Space: Yes No
_ . _ Method: Pumped - - � �Pr-;ssure � - Poured ✓ � �- �. � • •, -
Depth: From O to_ ��. � Ft. - �
Matenals Used: No. Bags Portland Cement Weight of .1 bag_lbs.
If mixtuie (sand, gravel; cuttinas) - Ratio: to �
�ID Plates: Yes ✓ No ' � � •- � .
�� 4 x 4 slab Yes—�—No �
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z HEREBY CERTIFY THAT THE ABOVE INFORM�1'ION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSO�I C�Vi�'I'Y HEALTH DEPARTMENT. �
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Signaturc oE Contractor Dat �
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