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A27 162� O � � V � a ��.� �'3�f � �N%���6 � ,��:_ -� ..�j � � � � `�' ��i W fl��-�L 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 :+�s € .e,n w`� '� . �- � ` . z , i y; � �� �� '� h w; �.�.�' �_: �s ` .s �'�'ater �ampre,�to�be`,Coll�cteci: s � � � � ,: ,�Y � ..,;:i . �._� ,. ,�> . ... ��� ; . r .. ._ . _ 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. � r� �r Q 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 � � w U � a 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 _�\ ��=M �-�y-g�•�C•C . � 90.00 . .� � � � '', : � .� • � ' � 0= 30 • 4- 3 6 �� , . R = 230. � . � �s . . . , 6 � ,. . . . . o�c = 121. 4 � , . '� ,. . . . • : S i3 -21 3 E � � :� ,� . . ' . � . .. 120 00� �� " �, . .. .. � �� � y,, � 2.14 t�c. � :. � �` � �� ; � �- � � . 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