A27 114dd
1�
Amount paid �� ' P
Re�'eipt �� ' � �(�G �
� � Y , CJ12 '13 `I��
APPLICATION
a t
' .3p :C fih iS � -.' ��'Zy_i3 �.c -�: H?F II:4g+¢`Y �''fs �.,1�' ' t.
i., L �,t S' � C ..x �%i`� it..?3'"`�i�' �,er��ic�sx�
��r . .� . w�«�;s � � � ::Y
r,= ,:.._....... >
Improvements Permit. (EstablishedlRecorded Lot)
ImpFovements Permit (Unrecorded Lot)
d
�a� ��
/ , � -� � _...
�o
SJ-1F-R�
Date
Reinspection of Existing System (Loan Closing)
_ Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) �Permit for New Well
Improvements Permit (Addition) _ Replace Existing Well
� v 4
n� e��r a z� � d�4k ' Z k"�.a.,x' -�;.`� � 't e y,�> '` `�� ��,r�,r.,.�Kx<'t�
� �t� � �� , �:� f=�ss3� Y� ;�y�,= ;:y� Ky�aterSample{o,�bexColl�cied_,x S¢�,,..:;�� .�
};��: 3 s m+ trFt., SS.:Rt<r �..s k.., a 3. ,..,.r�,.wa .�.., a..,�,.n,+— ,.... . ,. .
.. �...:..i.. . af✓,..rwi.:wi. .b> .. . .., . . � -
�
_ Bacteria _ Chemical _ Petroleum _ Pesticide
1. Permit requesied by: .
�wner/prospective o�ne[
�
�
w
U
�
a
w
�
z
ome Phone #:
usiness Phone #: �3�i- R�` l7y0
7. Dimensions or Proposed Structure:
Width: _
Depth:
_ Lead
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewag�,disposal sy,stem is intended to serve?
of current owner: 9. Water upply t} pe:
- ' . private . public ❑ community ❑ spring ❑
Are any ells on adjoining property?Yes ❑ No [�
If so, identify location:
. Property Description: Lot size: /.�.�(n Z�S
Tax Map#:_
Parcel#: �
Township:_
Directions to property: State Road #& Road
mes,�tc.� �,/ , � /
. �% /U, . Y�i L' [� ��Ya w/d !�d
Number of occupants or people to be served:
10. Type of structure/facility: Proposed: �Existing: Q
Type of dwe ling:
House: Mobile Home: C7 Business: ❑
Type of busi ess:
Number of Employees:
Number.of bedrooms: �
Garbage Disposal? Yes ❑ No
Basement? Yes ❑ No�If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PeI'SOIt COunty '�ealth Depat'tmeIIt 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 facilities 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 that before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the H lth Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application all �c¢me voi� a��i all fees paid forfeited.
I , ll, I
Si�nc Owner or Authorized Agent
l
• '
\
B 2376
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 #
Zoning
Owner/Contracto�
Location/Address
S.R.#
Subdivision Name /�,�,� �- D ��� e. (�( ; � � Lot# �
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area l,�Ip,qC. Size of Tank
SFD �,�_ Mobile Home Size of Pump Tank N
Business # of Bedrooms� Nitrification Line �/b��i�3 �
Max Depth Trenches ��/ � �
W . . ���y�)
v Permits may be voided if site is altered or inten d use changed.
Well and Septic Layout by
a Comments: �
_ 51 e�
IDate /-Zo�5�3 Install� by L.��,i T�s�;.r Approved
Individual
Site Approved
Well Head Approved
Grouting Approved C
Comments: ��,�
Date
�ln
� WELL SYSTEM SPECIFICATIONS '
_Semi-Public Required Slab C
Replacerr}ent Air Vent � G
✓ Required Well Log �� C �'/�/q �
C/ Well Tag c�C�
8
� I bZ�' � �}--� L� 5(� �. 1r�om �0-�C.c. P��
r
Installed by ,�iN 1,�,'u ;�,,.S�Approved by
This report is based in part on information provided the hoineowner 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 environme�tal 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
�j Q,, .
"� , UD LF = 7 � �' }a� �U Q1: -
Z� � i�: '�
,gL bbF=�'
:--:,, .
„ -`�,90�'J -Fl. 5 ; . ,
� 0,9�' , . : ; �� .
\� , g/ r?9 = 7 �.' -g��� • ' '. ,/... , � • ��`�-�.r �
��� gl bbF= h� ,.� � �: . �'.� . � � ..
�.; c5/ � .. , / . , �� Y . . ..
� 3b 6� a�1= � ��.�� " , '� . ��:
1, ' ' � _ �_r �� , .� : : ' _ � . . .
1- -_�' `~f • . J '. {�_
f �� «
��-'""_ � 9L " ti' ` ,.
v_ . L ,.. r / . �� •
,�� 8� � z 9r � r.� � �, . � , � �'n 9�' I
�., Zc� � - .
: � � 8 � _ �- �'� .; .
. r_.^ . � ,,.� / � �; . . f / .
,�.,�
_ -- � � �� o\� a �� � � . . . •
!` _ _—� 4 � /� ';� N .
, G
4
�� � C� 41 i �
! , �.� �� : � .
, vs �,z = � �, �rar . � .
, 6L �Gl � : � 3 ,,� / ,..
, , �, J/o = C = �' .� � \r�' .
", � �� ; � ' . •
� � ��ra� � � . . .
C�� � � .
�� � � �
o � `� ? , .
�a��x � �� v, �ti . . �.> . : .�J
� � . _ � j� . � a4
� � , ;,:. . �.�� o�i
.. �. ' I � . `l, . 4 � .., r �' V ' . , � � �
� � �a
� �
, � � ,: . ��2 , � � , 1:, : �� . . .
i�,�� -�a . �� �� �� � . .
��
'. � r.�'✓i� :.e`� j /�
, � g� � t., . �� �� ����� . .
� ('y�� _ . . , ' . `� � ���� y� � • � � . .
� �
�,� i+ . �' r
` � U'°".v, � .� ,
�, O ''fr4 v� rJ ,. , .
'� ,_ ^� Tr % ,
Z Q� r Q �ss� : ,, .. .
�' r+ ��0 � t
1� �� � a,�4 �.� ' � 1 k � � . .
� � I . • , � . ' O�� :.� + �` � 1, #�� � ' r � . ,.. . .
. � . • . . . . . . . •_
� ,; �. J .
, S� !^ M � . N'ii ' d' . } �. ' 1 O�•' . .
. � � � � . � � � 5 �,
� � �, f ,; , �p. � .
' ' � .. vw;, t r � � • . , �
. . ' . . ' �Ati �� ` . �.�� n�• ' . . ' . I �
'" Z
. ..,.. . . . . � :• ,� fe0�, . . '.`,"� L----
. . .,- .
,i�� ;
, � .. f.. , ���!; ..,' + ;'. �
•;, ..
� t .. tt,..� I ��
, • � • t +�f+�lV. , Y I • � 1
. � �C� �,� �> � r,� w .b , . L�
. - . ���; �-��.." . t � � - �\ p ( (
.Y,'��- '����� �- / `
i5 (/ � ( \ r
� Q� "� x: �r.� � N I �}� !' V\ i V l.. ��i ! 1, I
(,t • ' . ,� �` `:. ;;� .2 . •
3 �2 �' . , . _ � � ,.. .
�e��r � . . '�` �� � �
.,. �
� . . �y: . V1 � •�
. ��` X`�p
��; 'N � �.�`
. ' \�v � �j�Q/�
` y ,p„ V�" V
� p, ` • � Jy� ' y
�'� �° ~ V �° �
pk ��. �, � �' � � �� � d' �, � _ � J o��,�..
� !�� ,�d''� N � y `�-, � 4 - 3 %D. T9 �
� a S � �- 2' % SO
. . lp�p �, � . P � u9 " � �.
i 'Q�� v�,��i 'S: '. � �, �4 V�. • 1��
��i ,�,o �i
90'� � f v aDp'� N b`' y`� �,i _-�r—
�GC � � �� 4q � _ ... ' _��
. � . r��
/ +' • � • _ . -� .
D��� `� . � y�`
� �� -. .,-- g .
Q. � �� �-- ► , �2 �, � .
�. �6 . ��, . � �� � 46 . 76� 22.38 .►N _`J
% ' � / i� . , �' �
.�. • ,; . .I . -
• r�.. . ' , . - J-� .
. . .. . . � ' . �-- -
' ' , �i ' • ' . �6 • �'JQ ' /�� �9 ,7P dl
� . �. ���': �.� . ..5�` �,j . � /� . � R_ 344 7B , � .
�-,.� ' . .. � � : � . 8:3�" :� c. - 6e �B �
� .� � .0 �
• : � � � 5.86 � �
. . = �oa:� ,.
'� � ��i�Q� � : R= 344.'7B � ��
� �� L ' 3T OC) � �_
70 h
� 3 � � , ' ��
� . �,' �-rp�g�Q,��qUNTY ENVIR4NMENTAL H�ALTH
� , �� � ��A�. tu�
WELL LOG
Date: � � S.rC � Q � SR# .
Owner:
Lc�.;ation/Directions: . .
. �
�,,L L�t � 2.
Subdi�»��on Name: �N �
Drilling Contractor: �a �
1NE
Dist:uicc from Ncarest Properry Linc -
]��swncc from Sourc� of
Pollution
Total.Jep.th: F� Yield: 5 GPM Static Water Level FG
Wa�er Bearin� �ones: Devth Ft• F�- F�' �t'
to Ft. Diameter: � Inches
Casing; Depth: Fr�m Galvanized Steel '�
TYPE: Steel �
If Steel, does owner approve: Yes N0- Inches
Weight: Thickness: • Height Above Ground:________.
Drivc Shoe: Ycs No --------
Were Problems Encountered in Setting the CasinB? Yes-- No-
;f "ycs" givc rc:ison:
Gmut: Type: Neat Sand/Cement ✓ Concrete
Arulular. Space Width 1 Inches
Water in Annular Spacc: Yes__... No_.._
Method: Pumped- Pressure___.___ Poured ��,_
�. Depth: From � to 20 Ft.
Materials Used: No. Bags Portland Cement______. Weight of .1 bag______lbs.
7f mixture (sand, gravel; cuttings) - Ratio: to .
ID Platcs: Ycs '� No
d Y d clah Yes ✓__ No
I HEREBY CERTIFY THAT THE ABOVECCORDANCB WITH REGU A ONS SET
T H I S W E L L W A S C O N S T R U C T E D I N A
FO R T H B Y• T H E PERSON COUNTY HEALTH DEPARTMENT.
. , • �-3 =q 8
Signar�re of Contract � Datc
�