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�marovements Permit. (EstablishedlRecorded I.ot)
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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) �a�-hl-o oM _. Replace Existing Well
Permit requested by:
�ner/nrosnectiVe Own�
� . Dimensions or Pro osed Structure: ��� ��;
� idth: c�' .�� f3 a d,►., rooµ .
Depth: �� /D � 7 r—_x� s ��� �S��f�X�
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
ome Phone #: �1 �d =��I� �� �9
usiness Phone #: �
and �.ddre�s of,cu r�ent owner:
' A
�
Lot size:
. Tax Map#: �rAr�
Parcel#: � ' 9 �,s�
Township:.����-�-��� �
. Directions to property: State Road #& Road
Zames;�tc. ,�a , �
Number of
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
reby make application to the PersOn County Health Department for a site evaluation for the on-site
age disposal system for the above described property. I agree that the contents of this application are true
represent the maximum facilities to be placed on the propercy. I understand if the site is altered or the
nded use changes, the permit shall become invalid. I understand that before an Improvements Permit can be
�ed, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
ivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
site by the Health Dept., this application shall become void and all fees paid forfeited.
z
or neople to be served: z
that th' sewage disposal system is intended to serve?
���� �� � ��.�
9. Water su ply t}pe:
private ,f�. public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No [,�
If so, identify location:
. Type of structureJfacility: Proposed: �Existing:
'fype of dwelling: } ��` �°�M
House: D�Mobile Home: L7 Business: ❑
Type of business: �:�2it�rn�
Number of Employees: �
Number of bedrooms: �
Garbage Disposal? Yes � No �
Basement? Yes❑ Nofl If so, # of basement fixtures:
� ' �. � �-
Signc� Owner or A thorized 7Agent
permit Issued ❑
Permit �efii�d �
Plat Observed ❑
Signature
I. SIAP£ (A)'
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3. RFSTRICIIVEHORRANS(iK.)
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SSUITAOI,¢ PSPROYLSIONALLY5URA6l.E UdMSUCTABLE "
RECOMMENDATIONSlCOM MENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fil'
areas, wells, water bodies, slope pattems, etc.) C:WM[PRUDOCS�APPSEC.SM FINANCEF`
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT PERNIIT
B 1244
Not for waste water system construction. No permit(s) for Construction Location or
Rel�cation A�tivity shall be issued until Authorization for waste water system construction
l�as been issued.
Tax Map #� � � Parcel # �
Zoning Township
Owner/Contractor '' � e � � � � ��,� � y�, n n Date / 0 T / � - -�f �
Location/Address _� rJ n� J Y,K, o�. �� i � s- f- ,�� � f crt �tt 13 y Z
Subdivision Name
siness
s.R.# s � No,-�
Lot#
SEWAGE SYSTEM SPECIFICATIONS
Lot Area v Size of Tank �Q��% ��',�' ti�
Mobile Home Size of Pump Tank n»r�- �
# of Bedrooms. 7 Nitrification Line �Dp � X 3�
I ! +,� `�ge��
� � .. �1 L'"�".'1 (U l�'f��°M � S:
,� �,,ou� , _
v Permits may be voided if site is altered
� Well and Septic Layout by
a Comments:
�
Max Depth Trenches � � �- � �
Date Installed by Approved by.
'�A�
Gomments:
Date
Installed by.
�`
Approved by
This'report is based in part on information provided the homeowne"r or his/her
representative in the application submitted for this permit. The environmental
health specialist is not respQ7sible 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
�
�
' PERSON COUNTY HEAL`TH DEPARTMENT
� WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # �Zlp Parcel # ��
Zoning Township i Y e ;1
Owner/Contractor�� ;JjQ�� � /�%; nQ � �- � n Date - - `
Location/Address �1 _�_'���- C�.c_,fZ�.�s -�'f �►r� `` k; n hl c�''
S.R.#"
Subdivision Name Lot#
A 1752
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area _ Size of Tank �( �C�CJ �-l�
SFD Mobile Home__ Size of Pump Tank ,
Business # of Bedrooms_____ Nitrification Line ���
��� Max Depth Trenches o'� '
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is alt or intended use changed.
Well and Septic ayout by
Comments:
Date
Installed
Approved by
WELL SYSTEM SPECIFICATIONS
Individual��Semi-Public Required Slab
Public Replacement Air Vent _
Site Approved ,/ Required Well
Well Head Approved - �— Well Ta �
Grouting Approved ✓ �v� S-19-99 ��
Comments:
Date -� Installed by � w�%.� - w'//%ans� Approved
This report is ba�se� in pait on infonnation provided the homeowner or his/her representative in the application submitted for this pemut The
envuonmental 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 wazrants that the septic tanlc system will
continue to function satisfactorily in the future or that the water supply will remain potable. c�amipro�permit.sam O1/95 rev.1.0
ORIGINAL
e PERSON COUNTY ENVIRONMENTAL HEALTH
��• PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: Parcel #
Zoning
Applicant: V ��� Yl(�lA� �I 11,�� /
LocaUon:
7ownship
Subdivision• Sectlon: �OL
TVpe of Water Supplv:
Re4uirements•
Well Permit
✓Individual Community Public
Site Approved by ✓2 � ��
Grouting Approved by - �
Well Log �- 2� � 0(�
Well Tag
Air Vent
Hose Bib
Concrete Slab
Well Driller:
Well Approved By: Date:
**See Attached Site Sketch**
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions: r��° S1� ��,�� �
PCHD, rev. 11/29/99
Application #:
Tax Map #:
Parcel #:
Person County Health Department
Environmental Health Seciion
SiTE SKETCH
Wll �r�� �'��� �eo ��ru�,��.
Applicant's Name Subdivision/Section/Lot#
.�iILN."I : •� /.>l /.//�%JI � �r/
/ . -. - �.- �- -
Svstem components represent approximate contours only. The contractor must flag the system
to bePinnin� the installation to insure that proper grade is maintatne�
� �.�a�[e � �� Pe� v� �-f� .
�r
� o( W,e�jy
25' �i
��,oc,��
.. - I �� � ,
ca.�V��t- �� l��so�v��
v�� � d'i�cl v��
r�;�Cc a���v �!�9
� ���� ���
D�G��v�ar��e.
PCHD, rev. 90/12/99
;�� � �
. � ' � : � .
� � � 5� —9 °
Date: — ..� h
Owne: .
�,�cati�n/Directions: .
P�RSON COUNTY ENVI80NMENTAL H�AL1'H
WELL IAG
SR# - , •
���
Sub i sd ion Namc: „ , . , � �,y � � � �,�nn c S.►s �
Drilling Cbnt�actor: _: �'�
�_� L�� � Distancc from Sourca of
D�tur�ca from Ncarest Property
Pollution �� GpM Sta;ic ytlatet Level FG
'- 7ota1 �aP�% ._. F� Yield: . F� F�i '�G
: Wster $earing Zones: Depth � / ches
Fc. Diam� �
:��, C�.sing: D�pth: From d._._.co ' ed Stecl
. �I'YP�: Steel ' Galvat�
.� If �teel, doe� owner aPProve: Y�s No_______
Thickness: ' Height Above Grourid:_„__.__ Inches
' Weigh� �
' Drivc Shoe: Ycs No - . . _
�� erc Probl�rns Encounte�tcd in Setting thc Casing? Ycs,_ No_._._._
. w
: � ;; "ycs" givc rcason: Coricrete
Gruu� 'T'ype: Neat _. SandlCement_ —
. �. . � . �,r,��.spa�w�a�n �� ��n�s
_�� Water in Ar�ular Spacc: Yes_ No�._.
. Method: Pumped� Pressure!_.. �ourcd •�... �.
. . �epth: From � to � F�'
., , ga po�d C��t�_ Weight of 1 bag,.....r_lbs.
� � . . Materials Used: No. &S . �atio: t� �
� Yf mixture (sand. g� v�l; cuttimgs) . ,.
7n ri��s: Y�S No._-- •
.
� ,, „ 1 �,,�, vA� � _ No - `,. ,
r HEREBY CERTIFY THAT THE ABOVEYNFORM�TION IS CO EG �,�ONS SE'I'
THIS 1�IELL WAS CONSTRUCTED �i ACCORDAI�ICE Wi'I'H R
; � �^,';•� �3 j ': ; ;� PERSO:�' �QUN"fY HEALTH DEPARTMENT.
. .
. , � _ ., ,�,
` � Dat�
_ � Signarirc of Contract •
Date: �-2-2�6�0
Ow*�ei: �
Location/Dixections:
P�RSON COUNTY ENVIRONMENTAL H�AL'1H
WELL L' OG
�
Subdivision Namc: L�t �
Drilling Con�ractor� ��J��N u�� �" ��M Sa� T-� �
WELL CONSTRUC'I'ION
Distance from Nearest Properry Line Distancc from Source of
Pollution
�. � T�otal.rep.th; Zd� F� Yield: � GPM Static Water Level Ft.
-. Water Bearing Zones: Depth Fi•-Ft• - F�'� t�ches
�- .: Casing: Depth: From____�___to��Ft. Diameter: 4
� . � TYPE: Steel � � Galvanized Steel '�
If Stezl, does owner approve: Yes No
� Weighr,_____ Thickness: • � ' H�ight Above Ground:_______ Inches
Drive Shoe: Yes No _ � . _____�
Were Problems Encountered in Setting the Casing? Yes_____�. No_
� � If "ycs" givc rc;�son: .
vrout: Type: Neat _ Sand%Cement Concrete
_ � Annular. Space �Nidth 1 Inches
�� � ��iater in Annular Spacc: Yes__._. No_._.
- �. . _ Method: Pumped � _ Pressure__ Poured �=
�. � Depth: From O to 20 Ft.
Materials Used: No. Bags Portland Cement______ Weight of .1 bag_lbs.
- Yf mixture (sand, gravel; cuttings) - Ratio: _ to �
TD Platcs: Ycs; No �
4 x 4 slab Yes ✓ No____.�
I HEREBY CERTIFY THAT THE ABOVEYNFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED 1N ACCORDEINCE WITH REGULATIONS SET
FORTH By•THE PERSON COUNTY HEALTH DEPARTMENT.
. ,'
Signat�ire of Contract � Datc
�
,-� AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
- (Void sixty (60) months from date of issuance) y
� DATE:���� IMPROVEMENT PERMIT #: % �
TAX MAP #: ��_ PARCEL #:
OWNER/OWNER'S REPRESENTATIVE: I�l I bv ✓� / �� h� �.�l�y �'"�
LOCATION/ADDRESS:
�� n) o� o n � f ; �s �,�� sf s�� /.3 y2 �1�� �
� ` T �
�-bu � o� � f ,�� sfi r,�����Y �3Y�h h s ��S ��y,���
SUBDIVISION NAlV1E:
SECTION OR BLOCK:
AUTHORIZATION FOR CONSTRUCTION ISSUED BY:
AUTHORIZATION CONDITIONS
LOT #:
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 Pernut #�/2 �j . 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:
�M r
�' �C` �C� u
/
l� �t (f /� A / 9
� � S e,p�r �
Person Requesting:
Y
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S '
Gl ��OJ
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