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Improvements Permit. (EstablishedlRecorded Lot)
ImpFovements Permit (Unrecorded Lot)
_ Reinspection of Existing System (Loan Closing)
lace existing Septic System
Improvements Permit (Mobile Home Replace) �Permit for New Well
Improvements Permit (Addition) _ Replace Existing Well
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` . z , i y; � �� �� '� h w; �.�.�' �_: �s ` .s �'�'ater �ampre,�to�be`,Coll�cteci: s � � � � ,:
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_ Bacteria � _ Chemical _ Petroleum _ Pesticide
1. Permit requested by:
�wner/prospective own�
ome Phone #: 9'/� '�y�/! g��
usiness Phone #: �'�Q - -�1 //I
7. Dimensions or Proposed Structure:
Width• �.g
Depth: a �
_. 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 address of,current owner: 9. Water su y ty pe:
' _ pcivate public ❑ community ❑ spring ❑
� ' -- Are any wells on adjoining property?Yes ❑ No �.
If so, identify location:
Lot size:
. Tax Map#: � ,� � �1
Parcel#: � G 6 �
Township: -
. Directions to property: State Road #& Road
iames;�tc.
Y C'SC I/1 n �
Number of occupants or people to be served:
10. Type of structure/facility: Proposed: C"7�xisting: Q
Type of dwelling:
House: ❑ Mobile Home: usiness: ❑
Type of business:
Number of Employees: 3
�Number of bedrooms:
Garbage Disposal? Yes ❑ No�
Rascm�nt? Yes ❑ N� +�f"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 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 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.
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z Signcc� Owner or Authorized Agent
Permit ?ssuec�.�
Permit Denied �❑ /
Plat Observed U/
Signature Date � : �C.6 '�f�. ' '
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.) C:WM[PRO�DOCSUPPSEC.SMFINANCE.PC
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B 1223
PERSON COUNTY HEALTH DEPARTMENT ' '
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT
' ._ . ,
Not for waste v�ater system construction. No permit(s� for Construction Location or
Relocation Activity shall be issued e: :�;: Authorization �or ��aste water system construction
has been issued.
Tax Map # /�l � `�% Parcel # %
Zoning Township ;
Owner/Contractor e�p S��nw►�oN Date ,�-i,� ��,
Location/Address � r1►'1% �-� �rL�- � ��4 Z � S`1 �) �,�� � �H�� sc��
I SEWAGE SYSTEM SPECIFICATIONS
E�epair Lot Area ac yrs Size of Tank ����J Cj�Nl
SFD Mobile Home 1 Size of Pump Tank N1 /�
Business # of Bedrooms� Nitrification Line t���� r�( 3`
Max Depth Trenches _�Q " — ,3� "
I��L� 6��
Permits may be voided if site is altered
Well and Septic Layout by
Comments:
anged.
Date ���- Installed by -� ��g�,� )����Approved byf�v�,�`��„�,,r�
'� -�f(� i,�i�
Well Permit Paid ELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab
Public Re cement Air Vent �.�
Site Approved � Required Well Log
Well Head Approved Well Tag
Grouting Approved
Comments:
Date `%-�i�-�j� Installed by.
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:\amipro\permit.sam O1/9S rev.l.l
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