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�Permit requested by: . �� Vf ��� ✓✓e�
wner/prospective owner/agent• .
�ddress: • - - -
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� Home Phone #:�
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usiness Phone #:
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. Name and address of,current owner:
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� Pr�oertv Description: Lot size:�
Tax Map#:
Parcel#: _. - .
Township: d r «P -
Directions to property: State Road #& Road
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7. Dimensions r ��osed Struc[ure:
W idth: - �
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8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
tha� this sewage disposal system is intended to serve?
9. Water supply t}'pe:
private�blic ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes`.f� No j�
If so, identify location:
�pe of structure/facility: Proposed: xisting: Q
Type of dwelling:
House:C1�'l�iobile Home: C1 Business: ❑
Type of business:
Number of Employees: 3
Number of bedrooms: _
Garbage Disposal? Yes ❑ No (�
Basement? Yes CCL�No�3 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 Pei'SOn COunty �Iealth Depal'tme ontents of th s aupli�ation ahe �rue ite
sewage disposal system for the above described property. I agree that the P
and represent the maximum facilities to be placed on the progercy• I understand if the site is altered or the
intended use changes, the permit shall become invalid. I understand that befo�s[and hat in the ev nt haveanote
issued, I must present a survey plat of the property to the Health Dept. I under ,
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date oE the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
. -- __ �..i —
Signc� Owner or Authorized Agent
permit Issued ❑
permit Denied ❑
Plat Observed ❑
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1. SLAPE(%) PS ' �c� _ PS � pS
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2. SOR.7FJC7URE(12•361N.) S S S
ISANDY. LOAMY. CIaYEY. NOTE 2:1 CL �Y) PS %' _� PS PS PS
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1. SOILS7TtUCTURE(12-361N.) S S
(MYEI' SO(IS1 S S� PS PS PS
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4 SOIL DEP7}I (IN.) S-�� y pS ps PS
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S. RESiR1CiIVE HORRANS (1N.) S S S S
(OdPERVIOUSSTRA7A.ROCK) Np PS PS PS
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6. SOlLDSWNAGFJGROUNDP/A7ER S
(DCiIItNALdQ�:TERNAL) PS NO PS PS PS
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�. SOII.PERMF�1BTLiTY S S PS
(PERCOIAATION RATE� PS . 3 �L PS �
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E. AYAiLABIESPACE p n�� PS ps PS
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9. SIIECLA$S1FICATION(SEEBELOW) � (
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SO1L SERIES
SSUITADLE PSPROVISIONALLYSUiTADLE U•UriSUTTABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns� eIC.� C:�AMIPRO�DOCSAPPSEGSAI FINnNCE.F'C
Amount paid 3�7�.a0 � �,� `��
Rc�ceipt 0� ' ► I ' ' � ` ' Date
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Improvements Permit.(FstablishedlRecorded Lot)
ImpFovements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home R�
._ Improvements Permit (Addition)
�.
Reinspection of Existing System (Loan Closing)
RepaidReplace existing Septic System
_ Permit for New Well
_ Replace Existing Well
�:;:�al ...v..f..♦ • > ..... .ur..-.� .:.. .....:.:..... .....�................
Bacteria Chemical Petroleum _ Pesticide _ Lead
Permit requested by: . 7. Dimensiop o� roposed Structure:
ner/prospective o ner/agent:� l✓�r�� Width: �'
dress: G�o:��� e� 12�• %2o�r/%��'o /`'�' Depth: �S'�
»�3 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 #: '
usiness Phone #: ��� ." �Jr�
Name and address of cunent owner: 9. Water su�ply t}pe:
�� ,� �, f r, private �public ❑ community ❑ spring ❑
0 9s, �j�,�o /-�C • 27.5'73 Are any wells on adjoining property?Yes ❑ No �.
If so, identify location:
Property Description: Lot size: �
Tax Map#: A �. �%
Parcel#: 2 ��
. Directions to propercy: State Road #& Road
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Number of occu
or aeonle to be served:
10. Type of structure/facility: Proposed: DExisting: Q
Type of dwelli :
House: Mobile Home: L Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �_
Garbage Disposal? Yes ❑ No ��
Basement? Yes LL��NoL7 If so, # of basement fixtures:
�
�
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PeI'SOn County T3ealth Depal'tlIlent for a site evaluation for the on-site
sewage disposal system for the above described propercy. 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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Application Date: � d( I�o ��� � f ���� �� Taz Map: /� 2�'1
Amount Paid: 7, 0 0 .._..,,.� •��- ������ Parcel#: Z.4{ l
Receipt #: �l 6 9' 7�
;Ena�vnn-ouass�vua��.Il ]I-3[<.�.Il��1z
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for Services
Services Re uested
❑ Improvement Permit (Site Evaluation) ' � „ . q� Construc�tjon Authorization
$200.00/$300.00 if> 600 d " ''� �` Fee is de endent on the e
❑ Mobile Iiome Replacemenitbr Building Addition , .❑ Permit Revision
$150.00 (if site visit recauired) - - ' • � $7.5.00 _
Well Permit
5.00
❑ Repair of Esisting SepHc System
Application: No Chazge/ CA $150.
1) Applicant Information: ' �
Name:. nC, Phone (home): �(fl- �22-Q355
Address: � ' (work/cell): � �(e- �$ 3� �e �
2) Name and address of current owner (if different than applicant): �, �'
Name: F �. � Phone:
Address:
2'l ,
3) Property Description: Lot Size: � 0.0 Subdivisioh:
Address and/or directions to Property: ���
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❑ yes ❑ no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems?.
� yes ❑ no Is any wastewater going to be generated'on the site other than domestic sewage?
❑ yes 0 no Is the site subject to approval by any other publia agency?
❑ yes ❑ no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
. _ - C1 i r
4) Proposed Use and Type of Structure: . �
❑Residential . ,
❑ New Single Family Residence Maximum number of bedrooms: / Occupants:
❑ Expansion of Existing System If expansion: Cturent number of bedrooms: -
� Repair to Matfunctioning System Will there be a basement? ❑ yes 0 no With plumbing fixtures? t7 yes ❑ no
❑Non-Residential
Type of business: Total Square footage of Building:
Maximum number of employees: , Ma�imum number of seats:
5) Water Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring"�
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes 0 no
Please note any l�own ground water restrictions or sources of contamination:
� If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional O Accepted ❑ Innovative ❑ Altemative ❑ Other --. ,, ❑ Any
,.— . . .
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I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, the site is subsequently altered, or the intended use changes, all permi'ts and approvals shall be invalid.
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Sign�ure (Owner/ Legal Representative*)
* Supporting documentation required.
1D ty t(�
ate
• Permits are valid for either b0 months or are non-egpiring when accomp�anied by an approved plat.
• A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
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B 238�
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.
Tax Map # ,� �.� Parcel # o� � �
Zoning Township �; J 2 f-� i� �
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area� C� Size of Tank I b C7d �
SFD r/ - Mobile Home Size of Pump Tank
Business # of Bedrooms � Nitrification Line �( C�Z� '>C 3'
Max Depth Trenches a �l "
Permits may be voided if
Well and Septic Layout by
Comments:
� .
Date
Installed
altered or �nten�d,�+se changed.
Well Permit Paid �� WELL SYSTEM SPECIFICATIONS
Individual ✓Semi-Public Required Slab �✓%5'/9S�'�y� -
Public Replacement Air Vent s/`I� � 9�L
Site Approved L,/� Required Well Log '7 q�Q'g
Well Head Approved '`� 5�� gc�� Well Tag �
Grouting Approved � q �Q �
Comments:
Date �'�5/9 �' Installed by -��i C�.�1.5 Approved
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 enviro�mental 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 remai� potable.
c:\amipro\permit.sam O1/95 rev.l.l
Tax Map: �
Subdivision:
��. ` 1 �f �JSL/ ��./ ��
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IE������m�.¢�.Il IE3C��fl�l�
Parcel: 2N 1
WELL PERNIIT
(New_ Repair�
Applicant's Name: F 4
Mailing Address: 121,o t,, �_
Qe�cF�rn _ t�IC 2?S'Tr{
Phone Numbers:
Location of Property:
Lot:
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulations governing construction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.J Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments: Q� rw� i{�d -�, ; r tf-Q 11 ,��nPr
Permit issued by: ��—„� ���
QI�TTew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 5. Morgan St.,Suite C
Rnvhnrn Nf 77573
Certificate of Completion
Date: I o--I-�- lG►--
LyLiner: w "_ w���s
EHS/Date
Depth: � o
Grout: �
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
17HCH7