A27 328� Amount paid . �� �00 � I 0�,� �� � n
., Rece�pt fE ' I�a � ['�� Date a �
� � � C� �b� � e n�r.rr_aTr�N rnR SERVICES
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Iw� provements Permic-(Established/Recorded Lot) ._ Reinspection of Existing System (Loan Closing)
Improvements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
�mprovements Permit (Mobile Home Replace) _ Permit for New Well
Improvements Permit (Addicion) _ Replace Exiscing Well
! 4 � `tt
•F �C:�.. ��.�-�iytr`S'F1.-�-5'Y.✓�S i�w-`'j�ater"Sam leto'„beCollecfed r h1j/�t�.�v'w.N.s..Y � �i.Se dr�s�`KS/�t�
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%� Bacteria _ Chemical Petroleum _ Pesticide _ Lead
"� 1. Permic requested by: .
owner/prospective ownerlagent:�
Address: ! � S' � lPrnn��' .�[-1�
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�Home Phone #:�
usiness Phone n:
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� 2., Name an addr
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l7. Dimensions or Proposed Structure:
" E�d Width: ��
Depth: (�
' 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?
n � v� .J ��
of current owner: 9. Water supply cy'pe:
� n S ��.f C�1 � .od� private �public ❑ community ❑ spring ❑
Are any wells on adjotning property?Yes ❑ No j�.
If so, identify location:
3. Property Description: Lot size: �. 3.�c, _
4. Tax Map#: ' 2� �
. �
Parcel#: _
Township: : - - �%l �
5. Directions to property: State Road #& Road
Names,�tc. , , , � � �� / �
10. Type of structurelfacility: Proposed: ClExisting: Q
Type of dwelling:
House:�1 Mobile Home: � Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �
Garbage Disposal? Yes ❑ No �
Basement? Yes ❑ NoL7 If so, # of basement fixtures:
6 Number of occupants or geople to be served• �� �
CLEARLY STAKE ALL CORI�IERS 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 contencs of this application are true
and represent the maximum facilities to be piaced on the property. I understand if the si[e 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 da[e of the evaluation of
the site by the Health Dept., this ap�lication shall become void and all fees paid forfeited.
SiQncc� Owner or Authorized Agent
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� PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT 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 # � 2'� Parcel # 32 �
Zoning Township � �;�/�, N; I�
Owner/Contractor '�'y��'�' �a��� Date I- $- 4 q
Location/Address
Subdivision Name
�
Lot#
SEWAGE SYSTEM SPECIFICATIONS
S.R.#
Repair Lot Area , G Size of Tank l�
SFD �� Mobile Home Size of Pump Tank
Business # of Bedrooms�_ Nitrification Line (�'X3 �
Max Depth Trenches o?� "
� � �.N 40 �VG �M-5 `R�s�r-�-e.�-I�en+
Permits may be voided if si ' altered or int ded use changed. �; H-e�
Well and Septic Layout by �
Comments: �Q�r e[�-QQ C� ( i�,�-. ,• L�L�
Installed by A proved b}�
nr1 �.�.° �f-1-y`1 � 1���
Well Permit Paid Ly' �VELL SYSTEM SPECIFICATIONS
Individual � Semi-Public Required Sla . ' �
Public Replacement Air Vent -
Site Approved Required Well Log �/�'N �} (� - ry-� 9
Well Head Approved � Well Tag��(� -�30 - q9
Grouting Approved - -
Comments:
Date /� -� -�`I - Installed
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 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 Ol/95 rev.l.l
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PLOT PLAN
J.D. WALLACE
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