A27 156Amount .�aid .
I �7, �o
Receipt . �� ' l04'T�Y
�-a9-q7
Date
. Permit requested by: . 7. Dimensions or Proposed Structure: I
,,.,,nPr/nrosoective owncr/a�cnt: r� _ � � � Width: �
�
a
W
U
�
a
�
d
�
¢
H
z
Depth:
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?
ome Phone #: �l�u ���`�� �
usiness Phone #: �11 q 54.�/ - ��o
and address of current owner: 9. Water supply t}pe:
� M� `� � � � S � private � . public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No �(.
If so, identify location:
Description: Lot size:
Tax Map#: � � 7
Parcel#: � � �
Township: h1'� �� R �� ��
Directions to property: State Road #& Road
vPr
of structurelfacility: Proposed: �Existing: Q
Type of dwelling:
House: ❑ Mobile Home: �Business: ❑
Type of business:
Number of Employees: o _ �,. '
Number of bedrooms: ��✓ j3� � �y�
Garbage Disposal? Yes ❑ No �
Basement? Yes ❑ Noid 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 PersOn COUIIty Health Depa ��e ontents of th s auplic tion ahe �e ite
sewage disposal system for the above described property. I agree th P
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 Health Dept. wi�in 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become voft� and all fees paid forfeited.
�� � Yl,',�, . � , w �CUYv�� —
Signca Owner or Authorized Agenl
Permit Issued ❑
Permit Denied ❑
Plat Observed ❑
Signature Date
�
l
.5- S- 9�
�
�
IK, - ....� .
�,�:' �C b+d F ; . .. �. .. 'y. $ �` �'� �'�' ..� .<. (3' 3n 'F .... ..... ' _�>� ,K �,.�.,ui' 7A � h..l.�a�v�3 _� . `2 �..ti'JY.'� ..3 � r �#-..3�.`i':
� � a" L .;< �ACI'ORSS1iEEVALUAj7oN�,� �'� : Ys ; � 3 � < d
.. .. 1 ... .. �7 � *..»t��� . .. .. _. . . r .. .. . .. .. ... . . ... . . .
tiaiss Y',......3�. x .� . . .. . . ... . :. ....,..: .
l. S1APE (%) S S S S
PS D_ i�) PS PS PS
�J �� U U U
2 SOII. TFX7URE (12-36 IN.) S S S S
(SANDY, LOAMY. CIAYEY, N OTE 2:1 CLAn . S /' � PS PS PS
�r+� o o u
3. SOTL STRUC7URE (12•J6 IN.) S S S S
(MYEY SOILS) �� PS PS PS
U U U
3. SOILDFPTti(iN.) S S S S
3� y PS PS PS
U U U
S. RFSfRICTIVE HOA120NS (TN.) S///��� S S S�
(IMPERVIWS SiRATA. ROCK) ��D PS PS PS
v u u
6. SOILDRAINAGF1GROlJNDWA7ER S S S S
tDCiF�tNALR WiFRNAL) Q� 9 PS PS PS
U V U U
7. SOII.PfltMEABIISfY S S S
(PERCOLAA710N RATE� �, ,3 ��C PS PS PS
� u v u u
E. AVAIIABIE SPACE S S S S.
� � �� PS PS PS
U U U U
9. SCiE CLASSIF1CA770N(SEE BElOV17 �
SOTL SERIES �
5-SUITABLE PSPROYLSIONALLYSU[TADI,E lbtlNSUfI'ADLE
RECOMMENDATIONS/COMMENTS: -
SITE CLASSIFICATION DIAGRAM (Include� Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns� CIC.) C:V�MiPR01DOC1UPPSEC.5A1 FINANCE.PC
� � , .
N � ;�
� _ ._... _:, �.,. .. ..
N /� � � 0 C ,p . O .��
�q — � � O
� � N �..
a m (�
��... �
.
�
Y
o��
., -
. s�
.�'.r N� J/
�� 33 . 3 • s2 -
o,� � s, 42,
� � . k�
, . �, Q 4,
� � "s- ,�
.s�. �
� , .�.
`,' C3'1 ..._
, � —
,
--o_
� '�; �� `�'4� �
•� • i� , C7
e•
. -
;
di o _
�� �
, '� ti
.... "o_ �? y a `�- ""
• s�, �
(J1 ..._ .��',� '`�
O N ��
0
c� �
,�: � .
��"'ei�"�� � . '. � � _ _ _�
' � p
. ON .
Ni!►
�
;' .
�
�
�
�
W
�
a
g 3065
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
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.
Owner/Contractor
Location/Address
Subdivision Name Lot# (
SEWAGE SYSTEM SPECIFICATIONS
Repair ��n0 ��� � Lot Area Size of Tank l� D�� C�P,�,
SFD Mobile Home Size of Pump Tank
Business # of Bedrooms_2� Nitrification Line � t
Max Depth Trenches � ��
Permits may be voided if
Well and Septic Layout by�
Date p � 22 —
or
by�J�/)►S Approved by.
Well Permit Paid C�'7 WELL SYSTEM SPECIFICATIONS
Individual�_Semi-Public Required Slab ✓
Public �eplacement Air Vent ✓
Site Approved_ Required Well Log ,
Well Head Approved ✓ Well Tag ✓
Approved No7 t,,�Z-Tn�ESSE.�
�•(%D P%� /}-�- f�P/1 C,-�' �nn � i1 V1/1 /
�i� 1��rlii%nii
-� �
Approved
This report is based in part on information provided the liomeowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or mislea�ding information
contained in the application. The environmental health specialist is also not
responsible for co�cealed 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 co�tinue to function
satisfactorily in the future or tt►at the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
� ,�
0
/' � _ � ' �-G
, � ��� �
� 1� � .
� � ���
..Z.25 I
4� � l�
. . � , '� . �c �V, �� a„�� �..�
, . • v. � O
. �a �
\\..�
o!/
C'
/ �
.r���o
� � J
_ . �o .� .
ti .
� �0 �� � �i �� ��,
_�
�
`' �h J o �,,����
01 �c. 2 �, l .5�' �����
�,�
. , � C�'�� '
. o �� `� �rp
:p
�`�
� • � '
. ,o �
� '' �
.� ,��'
_ i a - 32 . .- . `a���-��.
; oo , ,, `�
!•�SO•E � v ; � � s, �`
19� � �
� `
� � .
,o �L{� _ . _ .�
- � ,� -� - �
�
�
.�
'' SD'
(�
i.�J� C]C.
�a
0� �C.
<� ��
. _ � �2
. �° ` .�
� 1�
� �
�
,.. . . ) �,� ��
.�
� ��
���
�
�' SC
.
��
- .. ---------�--�._. _ ..
J
.i
. �
1( 1 l I( �
` 9 �IDYa 101�� � 'h
�
`� + u r U _ ,h� .
� r �� �� .
� I ' �.
.
� �'Y�yr�� � 2
� — ��� Sh�-�� o�
- — �a�s �rot o� �
P�� � � E .5o a�.
� P/�
j� - Z 2-�'
c1 Pl,2{�lS
9-13-99
-raoo
. - -- _.��z---------- ------------ ------- - -
PEKSON COUNTY HEAL'l,H DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # � % � _ Parcel #�
Zoning _ Township �
Owner/Contractor (�j/� Date - �
Location/Address�Z/�J� _
S.R.# /� !3
Subdivision Name -�� Lot#�_ �
SEWAGE SYSTEM SPECIFICATIONS
epair _ Lot Area Siz of Tank
ED Mobile H e� Si e �j� _
usiness # of Bed ___. N tr� tio ��fn�
�� Max Depth Trenches
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or intended use changed.
Well and Septic Layout by � }��_,.__�'!
Comments: _ � � (�f
Date
Installed by
Approved by
WELL SYSTEM SPECIFICATIONS
Individual Semi-Public
Public __�Replacement
Site Approved�__
Well Head Approved
Grouting Approved
Comments:
� l�n) -�'i�
Installed by
Required Slab
Air Vent
Required Well LQ��—
Well Tag
Approved by
This report is based in part on information provided the homeowner or his/her representative in the application submitted for ihis permit. The
environmental health specialisl is not responsible for false or misleading infomiation 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 wazrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable.
ORIGINAL
c �amipro\permit.sam O1/95 rev.1.0
C'�
PERSON COi�NTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: / 1 �� Parcei # l l 4�
Zoning
Township �` ` � l � -
Applicant: �/I \Iw� 1 r\ ��� � I I""" ""�
Locatlon: ��70 V �..�� � I ��
Subdivision• ����✓� ��Vr Section: Lot:�_
Well Permit
Tvpe of Water Suualv: ,/ Individual Community Public
Requirements:
Site Approved by �
Grouting Appr ved by
Well Log -�
Well Tag '
Air Vent �
Hose Bib
Concrete Slab
' !♦
� /
� �::�s.��'':: �/1 / %i9� �
� . . . - . ��1 ' � /JL�,� � i
Date: 7i'�% �
**See Attached Site Sketch**
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditio
PCHD, rev. 11/29/99
� • T
Date: `' � '
Owner.
L,oca[ionjDuec ons:
Subdivision Name:
Drilling Contractor:
PERSON COUNTY �NVIRONM£NTAL HEALTH
L�
4iELL LOG
Lot ##
WEI,I. CONSTRUCI'ION `-'��
Distance hom Nea.rest Properry Lin�_. � Distance from Source of
Pollution /(�O ''
Total Dep.th:__ !�[� _ F�. Yield:__,_/ S__ G1'M Static Water Level �.�- ;: �
Water Bearing Iones: Depth �_� �=t._ �_F� /b F�� �t.
Casing: Depth: From C,� t�__1� Ft. Diameter:�__��_____,_jnchc:;
T`fPE: Steel G21��anized Steel ✓
7f Steel, does owner ap�r:o��e: Ycs No
Weight: Thic�;nessT Iq�4 Height Above Ground:__ }�- Ir,�hes
Drive Shoe: Yes_,,� I� o
Were Problerns Encountcreri in SeninQ the CasinQ? Yes Nn ,
If "ycs" girc r�ason: -�'�
Neat Sand/Cement Coricretc �
Annuiar $pace Width Tnches
Water in Annular Space: Yes No
Method: Pumped �- Pressure . Poured cf .
Depth: From .0 7 v Ft. . .
MateriaLs Used: I�Io. Bags Portland Cement Weight of .1 ba� lbs.
If mix[uie (sand, gravei; cuttings) - Ratio: to
ID Plates: Yes +./ No � :. �
4 x 4 slab Yes ✓ No
Grout: Type:
7 HEREBY CERTIFYTHATTHE ABOVE iNFpRMATION IS CURRECT ANDTHAT
T�S WELL WAS CONSTRUCTED II�I ACCORDANCE WITH REGULATIONS SET
FORTH �3Y THE PERSON C0�?�(TY HEALTH DEPARTMENT.
` - �_�
ignaturc of Contractor Da�c
TO'd 5LZ6-865-9E£ 6ui- L L!--�a L LaM a��.au..iE9 `dZI =L0 G6-LZ-��O