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Am�ount paid . 6
Receipt .�� ' �����
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+ 7. Dimensions or Proposed SCructure: I
1. Permit requested by: . I .
�.u�Pr�nr�tnective own�r/agent: / ��_ Width:
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usiness Phone #:_
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8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility .
that this sewage disposal system is intended to serve?
s of cunent owner: 9. Water supply type:
� � . private �public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No [�.
If so, identify location:
Description: Lot size:
Tax Map#:
Parcel#: �
Townshin• � UQ � �
,
Directions to property: State Road #& Road
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10. Type of structure/facility: Proposed: �Existing: Q
Type of dwelling:
House: �I Mobile Home: C� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms:
Garbage Disposal? Yes ❑ No •
Basement? Yes❑ 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 PerS0I1 COilnty HCalth Depaa tm contents of th s application ahe trueite
sewage disposal system for the above described property. I agree th
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 tha[ before an Improvements Permit can be
issued, I must present a survey plat �of the pro y to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to th ealth Dept. wi[hin 60 DAYS after the date of the evaluation of
the site by the Health Dept., this applica ' shall t�come voi,)i an� all fees paid forfeited.
i�
Si�nc� Owner or Authorized Agent
Permit Issued ❑
Permit Denied ❑
ptar (1hcPrve�i n
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RECOMMENDATIONS/COMMENTS :
STTE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.� C:V�MIPRO'1DOCSlAPPSEC.SM FWANCE.PC
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B 1591
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlvIl'ROVEMENT PERMIT
Not for waste water system construction. No permit(s) %r Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # � 2� Parcel # �%�o
ZOrilrig TOWri5t11p i�VP �j l�
Owner/Contractor �C,��q �� Date �f -� q r7_
Location/Address 5�I n! �f•� SlD �� �f �.e.��__ dl�� f%'ll R��IP�iRK
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area .3� ,5„�, aw<f Size of Tank (UQD �' ��r
SFD �/' Mobile Home Size of Pump Tank N; �
Business # of Bedroom� Nitrification Line ,�/� ��( 3'
`r� Max Depth Trenches
Permits may be voided if site is altered
Well and Septic Layout by__�
Comments:
use changed
Date Installed by Approved by
,,�, . � e c � U _2 . /� n . - -
ell Permit Paid ❑ WELL SYSTEM SPECIFICATI4NS
blic
Semi-Public Required Slab
Replacement Air Vent
Site Approved Required Well Log
Well Head Approved Well Tag
Grouting Approved
Comments:
Date
Installed by Approved by
This repart 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 taak system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amiprolpermit.sam O1/95 rev.l.l
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