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.AePFLICA'TIOPI FCR SEFiVIC�S
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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!
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'or Legal Represen�tive
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PCND, rev. 06l27/02
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�Ppiic�� Da U �d. � !l
Subdivasaomm: � /
Se�taon: ��
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'�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
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PC.�ID, rev. 09/07/01
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���.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
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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