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Permit. (Fstablished/Recorded Lot)
ImpFovements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
Bacteria
1. Permit requested by:
�wner/orosoective own�
z
_ Chemical
ne Phone #:.� 1`(�-59a - `6� Slo
iness Phone #: G t �.- � 9-�1$ �
Reinspection of Existing System (Loan Closing)
_ Repair/Replace existing Septic System
Permit for New Well
I_ Replace Existing Well
r4A�N�b: w6'r Y l )�� F ���i&. � 1T' Y�"`� P�
tylIl��O �O;��OII�C�C(�%,�'�������,�'�i�
t
,_ Petroleum _ Pesticide
7. Dimensions or Proposed Structure:
Width:
_ Lead
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?
Name and addre�s of current owner: 9. Water s�}gply type:
� t � �� , _ ` ,`. �,,� � S private �� public ❑ community ❑ spring ❑
� ' - Are any wells on adjoining property?Yes ❑ No [�.
If so, identify location:
, Property Description: Lot size:
. Tax Map#: ��"/ �� � 10. Type of structurelfacility: Proposed: xisting: Q
Parcel#: Q Type of dwelling: �
�Township: ' � °`� �� House: 0 Mobile Home: usiness: ❑
. Directions to property: State Road #& Road TYPe of business:
lames;�tc. Number of Employees:
L Number of bedrooms: �_�,/
Garbage Disposal? Yes, �❑� o l�
, .�-, ,. �„�.,,,, �, Basement? Yes❑ Nol'd"If so, # of basement fixtures:
Number of occupants or people to be served: �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND TIIE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pet'SOn COunty �-Iealth Department 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 propecty to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
Signc, Owner or Authorized Agent
Permit Issued �
Permit Denied ❑
Plat Observed C�/
Signature
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C� � V� �.-1
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RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines; roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.) C:�AM[PRO�DOCS�APPSEC.SMFWANCE.PC
. .
PERSON COUNTY HEALTH DEPARTMENT
- „' WELL AND SEWAGE SITE, LOCATION Il�4'ROVEMENT PERNIIT
�
a
W
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a
B 1242
i'1ot 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 6een issued.
Tax Map # A�% Parcel # � s 3
n _ _ _ _ T 1 • /"� i . I
Owner/Contractor
Location/Address, ,� ;.,
� �'� r� � �
Date /� - 9-
�� �. v S.R.#
Subdivision N me ��� i P v �'vpv �'� �l/�.ot# �
- SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area r� � Size of Tank � h
SFD Mobile Home_� Size of Pump Tank n! l A
Business # of Bedrooms,�_ Nitrification Line f7
Max Depth Trenches �� `'
Permits may be voided if site is aitered
Well and Septic Layout by
Comments:
ged.
Date �'- , Installed by � i` ►��,�'� Approved by f��%���,.�?
n- 9- '�1 6 /L✓a
Well Permit Paid WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab
Public � Replacement Air Vent -
Site Approved Required Well Log
Well Head Approved Well Tag �
Grouting Approved
Comments:
Date . Installed by�'S�p -� y-1 ��� Approved by,
This report 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 tank 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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a=�.50-03 �
R = 350 . 00 �
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N -25-19-36• E
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= 350.00�.
o c = 245.3fi
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1.42 a�•
�=39-19-56
R = 260.00� �
a�c = 178 .48
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R � 200.00'
arc = 121.88�
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Sc�.�
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4=23- 12•1?
R=410.00'
arc = �66.OS�
S•08-09-1,3•E
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