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Permit. (Fstablished/Recorded Lot) _ Reinspection of Existing System (Loan Closing)
Impxovemen[s Permit (Llnrecorded Lot) _ Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) _ Permit for New Well
Improvements Permit (Addition) _. Replace Existing Well
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;5 �� f a s...£ •�a..-`.'�+,h'�+(� �f.w� �ater�aai�,X�e�o�,be�;CoYlecferl�� ,:Y fy,� �A$ Rj � •p:
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_ Bacteria _ Chemical _ Petroleum ._ Pesticide
Permit requested by: .
ner/nfoSDeCt1Ve 01�VriCI
ome Phone #:�
usiness Phone #:
. Name and addre�s of:current owner:
Description: Lot size:
Tax Map
Parcel#:
Townshi
- �7. Dimension or Proposed Structure:
Width:
,,� s �pth:
. Directions to property: State Road #& Road
Tames,�tc_ _ , ,�, ; _,� 1 � �
_ 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?
Number of occupants or people to be served: �
� Water s ly t}'pe:
private public ❑ community ❑ spring ❑
Are an wells on adjoining property?Yes ❑ No �
y
If so, identify location:
10. Type of structure/facility: Proposed: �Existing: Q�
Type of dwelling:
House: ❑ Mobile Home: Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: 3
'Garbage Disposal? Yes ❑ o �
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 PerSOn COunty Health Depal'tment for a site evaluation for the on-site
sewage disposal system for the above described property. I agree that the con[ents 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 Pecmit 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 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.
�
Signcc� Owner or Authorized Age
�
Permit Issued U'
Permit Denied ❑ /
Plat Observed l��
Signature
Date �� �� l � � � ' �
RECOMMENDATIONS/COMMENTS: -
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, s[reams, gullies, wet areas, fill
areas, welis, water bodies, slope patterns, etc.) C:ViMIPRO�DOCS�/+YPSEC.SMF7NANCE.PC
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B 1219
PERSON �OUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIl'ROVEMENT PERNIIT
Nc�t for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system� �an��ruction
has been issued.
Tax Map # � � Parcel # �
Zoning Township ' e 1- i
Owner/Contractor ' ' C �. Date �- �9 - -r'-� �.
3
Location/Address
,_ �, �_ -
sion T�fame
Lot#
R.#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area �< <� 2 c�.ir ; Size of Tank � «
SFD Mobile Home_�� Size of Pump Tank N!�
Business # of Bedrooms_� Nitrification Line �% t� a'x 3�
Max Depth Trenches � � ��
Permits may be voided if site is altered or '
Well and Septic Layout by �
Comments:
D�t� Installed by /�P
��� �
P�� ell Permit Paid WELL SYSTEM
t
Individual Semi-Public
Public - R placement
Site Approved
Well Head Approved
Grouting Approved
Comments:
, �, Approved by
Required Slab _
Air Vent
Required Well Log
Well Tag
Date 1 D- -� Installed by (�'� p,v�„ p Approved by
This report is based io 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 stateme�ts 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
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R = 260.00�
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R = 200. 00 �
o rc = 121.88�
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R = 260. 00 �
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arc = 314.50�
S•60-12-05•�
283.05�
12,0i-i�9s ���09Nr� FR��rf PERSOr� CrUNtY HEALTH DEPA T!J
��
Date: . 9-�� -9� �
Owner: �` ��, �'.
Location%D�rections: .�
/��'�d
FECtSON COUI3TY CNVIRQJ��fEN1'AL HEALTH
wELL LOG
18�44��1�13� �1 �� F. L��'
SR# �3�3 '
, _ ---.
Sub�ivision itiram�: .� G;,�� � .
Dzil�ing Contractor: y,�. y � Z , �.ot #
Distance �'rvm N'ea�retrPro r��LL C(�N TRU prj
Pollution F� tY �"'.ne Discance from Source of
To�al Dep.tli: ^..�3--,�_ �z. yield• .
Water �e�ing"Zanes: Dc t}� ��-- GPM Static Water Leve� � Ft.
, P t.,�F� FL
Casing: Depth: F��m-- d .�io �.3 '�",_ --`�t.
��.'P�: Steel . --�-----�t. Diametez: G % �.nches
�f Steel, does owner approv��y sanized St�el
Wei hc. --.--r—_No
� '��? • Th.ickness: �8 `"""�'`
I?rive Shoe: �''e� ✓� No ---.Heighc r�bove �round: l�� ��ches
��ere Problems Fncountered in S ne g the Casing? y�s � �' `
.�
Grout: '�' yQs 83ve reason: � �,� _ .
ype: Neat � � SandlCemenc Coric�ete
A.ru�u3ar. Space 1�idth � '
yVater in Annular S ace: yeS �ches
Meth�d: Pwmr.�ed P �`"' N0` '�---
�ressure
�epu : �ram � j ' ------ t oureti ✓
-��. ,____ to 02 o Ft. �
MateriaIs Used; No. Bags port�and Cement �Vei c of
�f mixture (,and, gravel, cuttings) - Ra�io: � 1 ba�9���bs.
. ID Plates: �'es �` i � �o�_ t�
4 x 4 sIab Xes �, No �
-,-�...,
� H�RE$Y CER I'TFY THAT'�-�� �3Q�E .tNFOR�I�,TIO�'
TI-�IS W �S CORREC'�' ANDTHAT
�LL V��S CCNSTRUCTEn �N ACC�RF�ANCE WITH REGU�.ATIONS S.
FORTH By�TH� PERSO�i r_pU`NTY H��,LTH DEP.q.RTME �T
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���n,1l�:c_ o�' Con,ract ,- —____..._.�
`�' Date