A26 3r
Amount paid ( �}%��d ..ly— -�� -"��
Recgipt .lf �' I 1 I� g ' • Date
�` � �- � � � `�' � R �ERVICES
• • � �PPLICATiON FO
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_ . . . . _. _...._.:.:.s-�..�,ro,:;.�.....,a.-,.�xrc>,.a�c�3�.'.;:'5�7,.....#�H_ ;n.� +s . , . , _. __ ..Ix„� �`%.s..-,ir., # 04.,3��.�:'k`.`r �f..d.a.H _._ ..
1. permit requested by: .
owner/prospective owne�
Address: �22d ory
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W
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ua
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ome Phone : �U �-f �� �� �
usiness Phone #: y��=--%�'l�
Name and addre�s of,current owner:
. Property Description: Lo[ size:
. Tax Map#: � � � � �
Parcel#: � �
Township• yr�r� �' �,��
.
S�f �
5. Directions to property: State Road #& Road
ames,�tc.
h%�'`ie�a %��'// � �G1/LJ?/l��h
7. Dimensions or Propose�St �t��
Width: � Y � — �
type (if any, additions, expansions, or
ient is anticipated to the structure or facility .
ewage disposal system is intended to serve?
� � �ti �
�, Water su ply type:
private �. public ❑ community ❑ spring ❑
Are any wells on adjoining pro ert ?Yes �No ��'
If so, identify location:,� � � � � �, � ���� `
10. Type of structurelfacility: Proposed: �Existirig: Q
Type of dwelling: ��
House: ❑ Mobile Home: �1 tsusiness: ❑
Type of business: ��'�� "
Number of Employees: � . :
Number of bedrooms: ���
� Garbage Disposal? Yes ❑ No C�
— Basement? Y-es ❑ No�If so, # of basement fixtures: ,
6. 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 PerSOn COun�y �ealth 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 facili[ies 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 tfiat before an Improvements Permit can �
issued, I must present a survey plat of the property to the Heaith Dept. I understand that in the event I have nc_
delivered a survey plat of the property to the�Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
Si c� Ow r or Authorized Agent
?ermit Issued ❑ ~ Signature • Date � • '
,.
Permit Denied ❑ , - � � ,
.:.. :...
Plat ObservedD �" �� ��� � �c'
. . ... . _ . .
. . ' -- -;
� �_
: : :�:-
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1. SCAPE (%) S S S .._ S.
PS PS PS PS
' U. U U ' U
2 SOILTFJCilJRE(12-161N.) S S S S �
(SANDY.LOAMY.MYEY. NOTE 2:I CLa� PS .. . PS ps . _ pS _ . . .
_ _ ' .. _. : ' . U ' U . _. 0. _.. :_:......;,.. U ..: .:....... . :..:. .?'.. .
3. SOILSTRUCiURE'p2•161N.) S• S S -- S' --
(CIAYEY SOlLS) PS PS PS PS .
V U U • U ,
3. SOILDEP77i(WJ S S S S
' ' fS PS PS PS
u u u u
S. RESI'R1CT7YE HORiLUNS (TN.) . S . . S - .. S � . _ 5 - . ...
(A{PERVIOUS STRATA, ROCK)_. _. PS PS .� TS PS
.. . .
.. . .. U. .. '.,.. _ U U;: . . ..,_,- U .... .
4 SOILDRAINAGFJGROUNDWA7ER , . _ .. S _ , . 5 . S - S . .. _, ..
(DCTFRNAL R WIFRNAL) _ PS PS tS PS '
� ' . V U� U U
7. SOII.YERMEABII]lY s S S S
(PERCO[AA710N RA'Itii PS . PS PS • PS
... :'F_'- . .. _.._ . U . U U U .
E. AVJ1I[AHLESPA�E �.. ; S .. . S S - S
.. - PS PS tS PS
_ . V ' U ' p U
9. S1TEC1JlSSIF1G770N(SEEBELO� . . . . , . : :
SOtf. SERIES : :' ' : ,; • : . . . � • . - ' . . .
• . . S-SUITAIILE ' PSPROVISIONAII.YSU1TADlE U-UPtSU1TABLE •
x�:COMMENDATIONSICOMMENTS: ` �
SiI`E CLASSIFTCATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, F11
areas, wells, water bodies, slope�pattems� eIC.� C:�AM(PRO�DOCSV�PPSEC.S�tFtNANCEPC
, ; � ��_ 30O � �,
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QB: 119-325 . � '. ..
Reams Claytcn
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1 .
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 # /� �j Parcel # 3
Zoning Township Q�iv�vtN� /f,9,M
wne Contractor /Qoy "�oCKy" G�4,1�'E2.�i2_ Date /2 23--9�
Location/Address ���1-M ��lc� �G A-i'�°�1C• G Oo � S o� �2.�,
S.R.# /339
Subdivision Name _ Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area S'�F ��t Size of Tank /aop a
SFD � Mobile Home ✓� Size of Pump Tank Oo a/ �F Nc�
Business # of Bedrooms 3 Nitrification Line S6o'X �oN 9�MiN
Max Depth Trenches «-�
Permits may be voided if site
Well and Septic Layout by�
Comments:
s�%'fL A-�
(l�'t�lfi�l���yL��IL�.-,.tr ,n/�%/I'L�:�.
-, , - ,. �
,:
Date a-/ �- 9$ Installed by �� �.g Approved by.
Well Permit Paid WELL SYSTEM SPECIFICATIONS
Individual�_Semi-Public Required Slab
Public Replacement Air Vent �
Site Approved Required We Log _
�
Jell Head Approv � ad�9 Well Tag �/
�routing Approved - �
Comments:
�� Date.
Installed by
Approved
E
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
�K� "
D�
...�at�:..�
Qwner.
PERSON COUNTY ENVIRONMEHTAL HEALTH
•• WELL LOG
Subdivision Name:
Drilling Contractor:
._. Lot ##
- i��-�-._ , _��� , � � ,,, . , ---------_..
WEI,I. CONSTRUC'I'ION � --�- -��
T�istance from Nearest Property Line_�_r�._ _ Distance frotn Source c�f
Pollutioii lo d ' �
"I�otal Dc �th la� � Pc. Yi�lr: Cil'M S[atic W::tcr I.,eve1�5` --- ;-�-
- � -- ----_—_ .__o_?Q._.....---
Water Be�ring %ones: Depth �/� ___'�t. �5'a FL 7s Fc._�la _�Fc.
Casing: Dept}i: From_�_t��-�---Ft. Diametcr:`-��__Ulc}i�;
TYPE: Steel_ '__ Galvanized Stecl f
If Steel, does ownerapp:ove: Yes No
� Weighc: Thicl:ness: /�� Height Above Ground:�^Inches
Drive Shoe: Yes �— No
Were Problems Encountered in Setting the Casing? Yes No --
If "ycs" give r�ason:
Grout: Type: I�Ieat Sand/Cement � Coricrete
Annular Space Width Inches
Water in Annular Space: Yes No
_ .. Method: Pumped � Pressure - � Poured � .._ . . . •, . : -
Depth: From C> :o �o Ft. �
Matenals Used: No. Bags Portland Cement Weight of .I bag,,,_lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Xes � No� � �� � .
4 x 4 slab Yes .. No �
I HEREBY CERTIFY THAT THE ABOVE INFORMr�TION �S CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH $y-THE PERSO�t C�Ui�ITY HEALT�� EPARTMENT.
. ,;
�'
• -.---
-Sig aturc of Contrac[or Datc