A27 175�' 1� ��
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P.C�' �._.�:.. .�
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:� ��� ... � _ __
mprovements Permit. (FstablishedlRecorded Lot) _ Reinspection of Existing System (Loan Closing)
ImpFovements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) ._ Permit for New Well
Improvements Permit (Addition) _ Replace Existing Well
_ Bacteria
l. Permit requested by: .
owner/pros ����ive ow,r}e�
A rirlrPcc� s�l'�
ne Phone #:y
iness Phone #:
N
_ Chemical I Petroleum
7. Dimensions
Width: ''L
Depth:�r
Pesticide
Proposed Structure:
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?
and address ,currgnt owner: 9. Water s ply t}pe:
private public ❑ community ❑ spring ❑
' � Are any wells on adjoining property?Yes ❑ No j�.
,,� A_� ,, If so, identify location:
Property Descriptio : Lot size: ,� � 3 S��--
Tax Map#:� Z.� ��- 3 0 10. Type of struc re/facility: Proposed: ClExisting: Q
Parcel#: ��%S s��va�- Type of dwel ' g:
,t......�..�.:.,. n 1 a- �re �l : 11 c.�K House: Mobile Home: C1 Business: ❑
� . . � .�- . •..� • : �..�
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�il = .i..u-. ' '�
�� .�� :_ti � � l�.�i� �`� � �' �:�.�.
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���- • • �. • �-.� - • .- ��
Type of business:
Number of Employees:
Number of bedrooms:
Garbage Disposal? Yes ❑ o "
asement? Yes ❑ No f so, # of basement fixtures:
L
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF AL
PROPOSED STRUCTURES.
I hereby make application to the PersOn County Health Depat'tment 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 [he property to the Health Dept. I understand that in the event I have not
delivered a survey ptat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this appli tion shall become void and all fees paid forfeited.
U�� • (%6L��
Signcc� Owner or Autho ' e Agent
. , �
. . .�
, • . - ,, , .
p�'�.',. ..
Permit Issued ❑ Signature Date ��" �-/ G
Permit Denied ❑
Plat Observed ❑
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�NDY, LOAMY. MYEY. NOTE 2:1 M1�
SOI[. STitIKiURE (1 b36 W.1
uv�r son.s�
SOIL DEPTti (IN.)
RFSiRICI1VE HORIZONS (MJ
dPERV10US STRATA. ROCK)
SOII. DRAINAGFIGROVNDWA7ER
XiERNAI.& Q:1'F.RNAL)
SOtL PERMEABtI1TV
ertcow�nox xwr�
AVAiLABIE SPACE
STiE CIASSIFiCAT10N(SEE BELOW)
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S-SUITADLE PS-PROVtStONALLY SUITADLE U-UNSUITABLE
RECOMMENDATIONS/COMMENTS :
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.) C:�AM[PR�DOCSA�SEC.SMFWANCE.PC
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• Harold N. W�nstead
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B 1241
� - -P�RSON COUN'T� H�FsLTH DEPARTMENT � ,
WELL AND SEWAGE SITE, LOCATION INIPROVEMENT PERMIT
4—�� - ivot 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 #_� �� Parcel # J r%5
Zoning Township �/,' ve �-1 r'l
Owner/Contractor o y� �,, //�s Date c/-�.?5 =�j'�
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area ,2,3� �� ���►s Size of Tank �• ,
SFD Mobile Home_� Size of Pump Tank �n
Business # of Bedrooms 3 Nitrification Line � D'f 3
Max Depth Trenches "
Permits may be voided if site is altered ' ten e se c anged
Well and Septic Layout by
Comments:
Date �� -Z� �(o Installed by �, Cd �U � Approved
4a, oo ..�.�,�,,,.�
Well Permit Paid ELL SYSTEM SPECIFICATIONS
ublic
ite Approved
�ell Head Approved
�routing Approved_
Comments:
Date
Semi-Public Required Slab _
tep cement Air Vent
Required Well Log
Well Tag
Installed by
Ap�froved by
This `'report is based in part on info mation 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
respunsible 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 th�,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/�5 rev.l.l
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Oct-26-96 07:39A Barnette Well Co. 910 599 0015
�• i PIItSON COUNTY ENVIRONMENTAL HEALTH
> , , . � - � ,
Date: ��� ��
. �� �
Owner: _CL�
L.ocationjD�rections: �
5� r,�a� �/� c�.� �
Subdivision I�F��me: .__�
Drilling Conaaciar: ���
WELL LOG
�jr'��� �n �c,��
!,�- �
P.O1
SR# ' �
�s���
Lot # -� �1
Distance frorn Alearest Property Linc �a ' D�stance,from S�urce of
Pallution IDp ' `
Tatal.Depth: l�ro ' Ft. Yield: 35 GPM Static Water Leve1��F�.
Water Bearing ?.ones: Depth 1,� F� /65 Ft / t� � Ft� �t.
Casing: Depth: Fram o to�_F� Diameter: �/y Inches
TY}'E: St�el � Galvanized Steel I$S
If Stee1, daes owner approve: Y�s No
� Weighi_ � Thickness: 1�$ Height�Above Ground: ��r Inches
Drive Shoe_ Yes„�No .
Were Problems Encot�ntered in Setting the Casing? 'Yes TIo ✓
If "ycs" give reason:
GrouE: Type: I�eat Sand/Cement �`� Concretc
Annular Space Width !� '� Inches
Water in Anriular Space: 'Y'es Na t,� �
. . �Viethod: Fumged - Pressure �?ouredi�
Depth: Fr�m o to 2rr� Ft.
IVlateriais Used: No. Bags Portland Cement Weight of.l bag_____]bs.
If mix�uie (sand, gravel, cuttings} - Ratio: ta
ID Plat�s: Yes r/ No =
4 x 4 slab �es � No
I HEREBY CERTIFY THAT THE ABOVE INFQRM�TI�N IS CQRRECi' AND THAT
THIS W�LL WAS CONSTRUCTED IN ACCORDANCE WITH REG[JL,ATI�NS SET
FORTH gy THE P�RSQN C^vt���T�C' HEALTH DEPARTMENi'_
-' � > � / r
r �.,-- /�
,��°--� ' f���,��' �
S' nature of Cancractor � Datc