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A26 78�atsticaticn Date��l-a9-t.� �lrnouni �aid• �e�9pt #: T.ax IAaA x� QaC� �arc�l �: %�i ���:�� �I��..� �� - - ---� � � v-��� - �m..��,�_.._...���.�. ��.�.a�. , �.�L .AePFLICA'TIOPI FCR SEFiVIC�S .• � 9F THE INFORM�►TION 1I�1 THE APPLIC.4TI�IV F�R AR! 1MPR�VEAAENT P�RflAIT IS LMCORRECT. F�ILSIFiED�, CHAiVGED OR THESRE IS ALTERED, THEiV TT9-11E iMPf�OVEMEi�fT PE33NIlT AND AUTH�RIZATi�Id 70 0 \\ C�NS'TRllCT SHALL BECONiE {NVAL6D. . - . ' " �, ,� '� � �1) Permit requesiec! by: t7wneclagerttlpros�aective owner): �Avt � t7 •�Q 1( �`�,�.�`�� . Home Phone: '��D . Address: i ioo 6ro;,�v �--�� T� C"' 4 Business Phone: -�l7 - �12y. . Z) 1Nam� and address of.current owner. �ol�.Tle e�/ � I�DD �oa ,5 �r�y_ 3) Property �escripiio�: Lot size: o� �:� s Trnn+nship: D� Directions to the �properk� (lncfudir�,g_ road names a�nd numbers): _ . D_) L_P.�-t ��s �, l� _ T Q,�.� Lot # 4) Proposed Use anc! Strua:ture Description: answer each of the follawing questions: . a) Proposed , Existing �/. Type of Struciure: Width: ' Depth: b) Number of Bedrooms: �_ . Number of oc�upants or peopie�to be served: 3 . c) Basemen� Yes �!IVo Will there be plumbing in itte basement? d) Garbage Disposai: Yes � No _ • 5) 1fVater Supply Type: Private �(new_ or existing �, Pubiic , Cammunity , Spring . , � Are atry welis on adjoining property? Yes Nn _ If yes, please indicate aaproximate iocation an the • site plan. � _ .. 8y Does your property c�ntain previvusly icien 'tdf'iecd juris�ciional�wettands? �es_ Me_J� PL�ASE P1OTE THE PaLL' OW1PlG: ➢�X PLl�T OF iHE PROPER7if. OR SiTE PL.d�AE INUSTBE St1BMITfEi� WR�i THi1S AF'Pl.1CATION. . ➢� PROP�RTY LIId�S AR�t3 C�RNERS Ml7ST BE C1.FARLY AR�RKED.. ➢'Y'HE PROP�SEfl LOCA�'If]N OF ALL STRUCTURES iMUST BE, ST.44�D OR F�LAGGED. ➢'�F�3E SITE MUST BE ➢2EA,DILY ACCESSIBLE FOR AA! �1/ALUATION �Y THE 4�fE�►LTH DE�,ART�iE�11T STAFF. � � { hereby make appiicatio� to the Pecson Count�r Health Department for a siie evafuation far the an-site sewage disposal system for.the above-described property. ( agres that tt�e cantents�af this appfication are true and represeRi the maximum faciiiiies�c�be ptac�d on the properiy. I understand ifi the site is altered or th� iniendecf use cf�anges, �ie permii si�al! � 'or Legal Represen�tive 9�a �-0.3 QatB PCND, rev. 06l27/02 � r`���' � ������ . �.'ti... ' r ' � '�Y `�1' 1V� .1L �L IE.����� �.@�.¢�Il IE"���.�a ;i��; ����a :��d . . .�.. - � . G ►. . . - • - • . . .. . -� . . � . . . . �e- D�� � � _ � • In. �■ �s ✓, r`_�s i, r . . :: M�I. :. r:�� � . ., �i:'�� : '. I : r^ :�.�-i' ./rJ I /: ��.�.�:-:..��•:�„ �.�. yi,�,� . . ,/' � � � � �" t/.:ilr../:.F^"/:: . -_� / � � �. :- -:!. � : .�. �f.-.. �..�r:..�r.« :i- IY� ' .ri- . ..�.: '� /�I•...�.-:: :.I. :•:. Y ♦ ':::.i�r� �. ::/..�. � .l. _ .I. �.., . .��. - r /�.a -..�:. � Id (,�� �'� -� . o�--� � � : m 0 li,�� .5��- I lu����� � -an9c, F1�5S � W 0� �/l S�KC r �4�-3�3, re�. fl9J�/fl1 ���.�� �'��..��� �-- �--� � � ��-�� ���������.�.�. ����� ����� ��� 5����A� ��F���������� �c� �� #: �t� ��� # '"'1 � �0�� �Ppiic�� Da U �d. � !l Subdivasaomm: � / Se�taon: �� � r-L, ,�a . �1 ba�. .� � r c� '�y�e oiWat�r �u��bv: V Individual Communitp Public. ��c�uireffien�. Site Approved bp ✓C�' � � �'-�'3-- Gmuting Apgsoved bp ��� ►d -�--�� Well Log �Well Ta.� Air Vent � I-�ose B� Concrete Slab Well �a�les H �s�� ��-+- �u�� Well.�pproves� ��r. I���• �°5ee Attached �at� Sfliesc3a'� Wells must be 10 feet from propertp lines. Wells must be 100 feet from septic systems. • Wells must be at least 25 feet from anp bwlding founda�tion. Qther conditions: "C � w� �t_� lYl,i�imc, �►�, c� F S(�` F�om L-I� T� K � �� n�a�ald� c��cl � � PC.�ID, rev. 09/07/01 ��� S ���.� �� �� oo � d�� `-- _'' .� c o sp� G`�l�ii�0 i—i l l I� ��(11�1 �,� L LL. ���.s�3YIl.'rn'T.C� � jLT� � ¢� D�ai�o Dr��[lo�l /�-/ O� �,�,� Well Log Owner: (�,v, 'i �i� Tax Map /�o?lp Parcel # � Location: � � � Subdivision: Lot # Well Construction Distance From nearest Property Line (Minimum 10 feet) Distance from Se tic System (Minimum 60 feet) (�() Total Depth: '��s ft Yield: M Static ater Level: �J� ft Water Bearing Zones: Depth ;34 3 ft� a� ft ft Casing: / 05 Depth: From `f-( to 4� ft. Diameter: �� in Type: Galvanized Steel Weight: � Thicla�ess: � b1�S Height above Ground: � in Drive Shoe: Yes No Any problems encountered while setting casing? Yes If "yes" give reason: Grout: Neat: Sand/Cement Annular Space Width Method of Grout: Pumped _ Materials Used: � Concrete GraveUCement inches Water in Annular Space Yes No Pressure Poured Depth to Ft. No. Bags Portland cement Weight of 1 Bag If mixture (sand, gravel, cuttings) — Ratio to ID plates: _ Yes _ No 4 x 4 slab _ Yes _ No Drilling Log Pounds Location Drawing From To Formation Q' � `�J J`� �Q� "!� � 3, e�tc � t ��'/ e�v � � l � a �4K- o � Ol� Q l��rb� (/��- � cS' 6 ^�J t. fL - R U S I hereby certify that the above information is correct and that this well was constructed in accordance with regulations set forth by the Person County Health Department. Signature of Contractor �.��u <, ID # ��� Date l�'Z�� PCHD rev O1/16/02