A27 160� o0
'�Amount paid �U . 7-���'I.
R�eceipt 11 � fD%,3( Date
� C�- 1 �• � e nnr.iCATION �O�Z_��•RVXCFS •
�
H
O
a
vements Pecmi�(Established/Recorded Lo[)
Impxovemen[s Permit (Unrecorded Lot)
Lmprovemencs Permit (Mobile Home Replace3
Improvements Permit (Addition)
Reinspection of Existing System (Loan Closing)
Repair/Replace existing Septic System
Permit for New Well
ace Existing Well
�
�
w
U
�
Permit requested by: . 7. Dimensions or Proposed Scn�cture:
ner/prospective owner/agent: Fi�=-� � .�f '�� Width: �� �
.i��n
.dress: 39�/ /� � -�� _ . Depth: a�' �
�. a,.�
' d � 8. What type (if any, additions, expansions, or
,:,, r �� replacement is anticipated to the structure or facility
c that this sewage disposal system is intended to serve?
�me Phone #: �"` �
usiness Phone #:�'�o S�'9 /��
. Name and address of current owner: 9. Water supply t}'pe:
S- T� • o G��u,,s � private�ublic❑ community❑ spring❑
,,v_ e Are any wells on adjoining property?Yes �I`Io [�
If so, identify location:
Property Description: Lot size: - SS
Tax Map#: .� �� —
Parcel#: / � � —
Township:_���t��// . —
. Directions to propercy: State Road #& Road
ames,�tc.
. 5'i A1 �
I0. Type of structurelfacility: Proposed: (�Existing: Q
Type of dwelling:
House: ❑ Mobile Home: Business: ❑
Type of business: �� �
Number of Employees:��/� .
Number of bedrooms: 3
Garbage Disposal? Yes � N - -
Basement? Yes❑ No so, # of basement fixtures:
6. I�Iumber of occupants or people to be secved: �_
CLEARI;Y STAI� ALL CORNERS OF TT3E PROPERTY AND THE CORI�IERS 4F ALL
PROPOSED STRUCTURFS•
I hereby make application to the PerSOn C011nty T:�ealth Department for a site evaluation f�on ahe o�el�e
sewage disposal system for the above described propercy. I agree that the concents of th�s appltcatt
and represent the maximum facilities to be placed on the property. I understand if the sice is altered or the
intended use cFianges, the permit shall become invalid. I understand that before an Improvements Permit can b�
issued, I must present a survey plat of the property to the Healch Aept. I unders[and that in the event I have not
delivered a survey plat of the property to•the Healch Dept. wi�ain 60 DAYS after the date of [he evaluation of
the site by the Health Dept., this application shall become votd and all fees paid forfeited.
�
W �
� .�r >
Z Signc� Owner or Authorized Agent
�
�
W
U
�
a
B 1783
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMI'ROVEMENT 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 # � a 7 Parcel # /�a
Zoning Township D ��v
Owner/Contractor �,�/�,Q(1t/ CfF�G��NT �i�e�vih nVr
1 L� L
Date �?-�-9rJ
Location/Address h�F J•;v� Src2� a�• r� r�cr�� rvc�,r,� Sv/3piuis� o�U
� S.R.# i3}3
Subdivision Name $6AU 2 ��G� Lot# [ �'
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area Size of Tank la�v Gs+.t(a+�� ___
SFD � Mobile Home � Size of Pump Tank N�t-
Business # of Bedrooms�_ Nitrification Line )�i,��'t L��G��� �� �
Max Depth Trenches e2 9� "
Permits may 6e voided if site is altere r' t nded use ehanged.
Well and Septic Layout by ' .�
�
Comments: /� ` �wu- rn�`•u.��
Date �-Sr- 9
Installed by `% '�''l L-�"�� J Approved
..,�a 4�. �o +7_29-q'7
Well Permit Paid C'� 'WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab �
Public Replacement Air Vent ✓
Site Approved Required Well Log ✓�f� `�J �SJf' � v
Well Head Approved Well Tag r/
Grouting Approved��� g � I��, �1
Comments:
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 remaia potable.
c:\amipro\permit.sam O1/95 rev.l.l
, �, y � ., .�
� � r �x ;;
::r�: � � � . r. - � {!�, ��� p . � �,� 1�' xr ` x �. r J � ( � � . q ,�'r! xk '�;,m t �C'e,5 f ::, i
;�
+� 4
t , � t . .,� u. , , � �, �, r r �v�y . , . .
� r '; � �.� . F . $ ��-i
, �' 6 tM S � � � .
. t j . . ; Q, �� ��� . R _
iK.� � N ��yF �. � 1 !
�'� +, i . r,. � t �a, t � } � S �� S
� � �{y . � . ., ;�,� L r ' , �.r<� .
�,.,,j iy �Yw� �w�i✓�, } }�;aka +.'v �I \tr�: ..F, �e �•;> \
�� w „� t n���h
,�. � � �X 41;.,,� ' �., �? � 4 ��g ¢y,�, , , V fi . .�
�{`'' �� ✓ ,�t a� t �' �� at d�, '-d w'Tti 1r � '�5 k t ��,y�v'� � �+�' 1 .� i :' Fi„ �� �/� �
�Y, h y tY � {" �i 9't ' "� R �y � �k;i . F � i'. .
Al ` (_}
f '4 (: � l Y � r S l �.,, ie� +5,' �� a , F ,�Y'Ff,'A � : . ,
x i ' � �,r�{ x�'s�� �„� , �� '�e�t/ �4~
��� �� t � '� P r, � '�'� &r �, ". f. ��� "Sf , � Ea"Y �� fk E � � :e�
_ _rv
��..�.
� w .+' � •-.M� , a�,�r,`.�':i�•�����y,^, ^ i u+.,.,�,. , -
� : S. l...: v i.4 �r� r.tt,idv -a'��St,A� i
���l�`a�dkrr_e�. ,. M' �'
t . �!
!4 �5 � � •
+ �� r' . �p � .
kv'i V Q
r . G � .
7 �
� � m
d
�� .1 .
� O y�
.�'i,., . . 0 ,
; a:;9
�^ �
t.:(;'
. �!" �
OO `, � . .
3�0• �
kk.�... � . �
� i
4' �'�� �
�;:; ;, . . �
�
�;' ' O � 8
� � � o:
,^ �:: � � '��13 n �
°� �<'' 22d90 � �1 s
�o � �7 I�
w�• y1 .
�O' p 1
�� �I� �+ W I�� W
�e O O, r
' � f � O, ��0
t,.,, . ` ` Q ��N i � �� m'- . i+Qi'�'• a �
H , �-^ '0 t� 'N R�Of� �
Vi � N�%�r N�F�
6p•t� / 1 � i u`o a� pN
2 a K �� �
W .d o.
�'; �Qjr �r
. ' . �� �';p��.A
• '±o � W �N u�M
.. �. - ,o p " o m
N� �D� p� �� p fl
s "';, M'^ �
f,
� + ;,? � a,
4� eN + 'f+�'O
r
W
r
(: .
f,^
Ng�OO
ft�—N�N
A� �f
a� �s
; •
� o <'.��
.. �o � �� O
.
u
o� �y N �
N;
N � q�
�`e�4
��
'�',q e
'r �,
��
u
O
• N �?
y
..�`°�-jA • Lf'
V1'694
.�o� N
. � �i .
C �
�"�+ � `:�
_�'
C
.
. • • . .
Date: '/�3 � �7 '
Owner. i= E'�-/
Location/Directions: _
.�.��Ue2 C�ee k� �_
Subdivision �N�une: ._�
Drilling Contxactor:.�
PERSON COUNTY ENVIRONMENTAL HEALTH
/
�
WELL LOG '
SR#
K� Lot #�
i/_; �,� . i i . . . . . --_
. WELL CONSTRUC I'ION
Discance from Nearest Properry Line /d Distance from Source of
Pollution �C�v '
Total D:ep.th: a,00 Ft. Yield: `�/ GPM Static Water Level�_____Ft.
Water Bearing Zones: Depth / 75 Ft. � Ft� F�. �t,
Casing: Depth: From_�_to 7S Ft. Diameter: /� rnches
TYPE: Steel � Galvanized Steel_ ,�
If Steel, does owner approve: Yes No
� Weigh[: � Thickness: ! d'Y Height� Above Ground: / �/ Inches
Drive Shoe: Yes ✓ No �
Were Problems Encountered in Setting the Casing? Yes No �,
Ir "yes" gi�e reason:
Grout: Type: Neat Sand/Cement ._ Concre[e
Annular.Space Width Inches
Water in Annular Space: Yes No.
_ .. Method: Pumped . ._ . �Pr:ssure � � � Poured �— .._ . . . ., _ :
Depth: From rs to a Q Ft. � �
Materials Used: No. Bags Portland Cement Weight of .1 bag__lbs.
If mixtuie (sand, gravel; cuttings) - Ratio: to
�ID Plates: Yes �/ No � � �� �
�� 4 x 4 slab Yes ✓ No
0
I HEREBY CERTIFY THAT THE A$OVE INFbRM�1TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERS0�1 COUi�'I'y HEALTH DEPARTMENT.
Signaturc of Contractor
Datc
C
�
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: '�-?� -�t� IMPROVEMENTPERMIT #: I���
TAX MAP #: PARCEL #: ��
OWNER/OWNER'S REPRESENTATIVE: �N�I�I ��I:C� ��
LOCATION/ADDRESS:
. ::..
SUBDIVISION NAME: �,��U�(�- C�%�G LOT #: �
SECTION OR BLOCK:
AUTHORIZATION FOR CONSTRUCTION ISSUED BY:
AUTHORIZATION CONDITIONS
1. The Wastewater system construction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Pernut #/�_. The
construction and installation must also meet alI applicable rules and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Healih Department.
3. Any atterations in site or soil conditions (inc(uding structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authorization and associated pernuts.
4. Conditions:
<< /
�'.,-.,�.. .y,� �Y .
Person Requesting: L��/ ��G���
�,