A27 3800 J
Amount paid ���!` , `�-�a���
R�ceip+t �� � IO.S�.� ' Date
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Permit requested by:
�s ective ownedagent: �� a�� � � �-�-�-
CQ s �, �-,,. _ n �� '. ,c... � -
— _ ,. � � _ �._ ,�
o e Phone #: 9►(� " S�l� —' OS�--I
usiness Phone #:`� l U—�i "�1�( 1--
7. Dimensions or Proposed Structure:
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?
Name and address of current owner: 9. Wa er supply t}pe:
��� � P ' private . public ❑ community ❑ sp ng ❑
Are an wells on adjoining property?Ye� No [�.
Y
If so, identify location:
. Property Description: Loc size: `1� �' '��--
. Tax Map#: -���—�1
Parcel#: � �' �
Township: � � 4 • '� `�1-a �
i. Directions to property: State Road #& Road
�tames,�tc. _ _ _ �
Number of occupants or people to be served: Z--
10. Type of structureJfacility: Proposed: [�Exis[ing: l,�
Type of d e ling:
House�Mobile Home: L� Business: ❑
Type of business:
Number of Employees: .
Number of bedrooms: ,�_.
Garbage Disposal? Yes ❑ No �
Basement? Yes ❑ No�,If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF TT3E PROPERTY AND THE CORNERS OF
PROPOSED ST'RUCTURES•
ALL
I hereby make application to the PersOn COunty Health Deparfinent 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 chat before an Improvements Permit can bc:
issued, I must present a survey plat of the properiy to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to-the Health Dept. wi�in 60 DAYS after the date of the evaluation of
the site by the i-iealth Dept., this application shall become vo[tf and a11 fees paid forfeited.
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z Signc.�i Owner or Authorized Agenl
permi[ Issued ❑ Signature Date � �
Permit. Denied ❑
Plat Observed ❑ �„
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1. SIAPE (%) S S S 5
PS PS ' PS . PS ,
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2 SOII.7'DC'{URE (12-)6IN.) � S S , S S
(SANDY. I.OAMY. MYEY. N07E 2:1 CU117 PS PS PS PS
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J_ SOIL S77tUC1URE (12-361N.) S S S S
(CIJIYEY SOILS� PS PS PS PS
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3. SO1L DFFI}i (IN.) S S S S
PS ' PS K PS
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3. RES'fAICiIVEHORTZONS(IN.) S S S • S�
(IMPFRVIOUS SiRATA, ROCK) PS PS PS PS
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6. SOILDRAINAG&GAOUNDWATER S S S S
(E7C'IF]WAL R II:IFANAL) PS PS PS PS
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7. SOII.PERMFJIBILTTy S S S S
(PERCO[AA7ION RATE) PS PS PS PS
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E. AV/VIaBLESpACE S S S S
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9. SITE CIJISSIFIGTION(SEE BELO�
SOIL SFR2BS ' . '
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SSUITAIILE p5.TR0YLSI0NALLYSUiTADLE Il-tA�LSUITAeLE
��:OMMENDATIONS/COMMENTS: -
STTE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, �ill
areas, wells, water bodies, slope patterns, etc.) C:�AMtPR01DOCSAPPSEC.S�1 FINHNCEPC
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81673
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IIv1PROVEMENT PERNIIT
r Not �or 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 # � � �
Owner/Contractor
Location/ ddre�s_
t' f�.o,,
Subdivisio Name
Parcel # 8
Township ' e i
� � �/.� � Date_r� - � � %
Lot#
SEWAGE SYSTEM SPECIFICATIONS
Lot Area ��. T � C
SFD Mobile Home
Business # of Bedrooms 2-
p � a 0 �hS�
/ S Y� v� �s` 1+�1 � C.o'�
Permits may be voi�ed if site is altered t
Well and Septic Layout by ,
S.R.#
Size of Tank / CJ(/U �/ _ H 1
Size of Pump Tank n/� �
Nitrification Line 3S�i 7�.3 �
Max Denth Trenches � � '� -
�,.. -{U �e �,r.� � �� �S�Ca� euc�.1'uve
.... ,.[..........7 • j NS�t � � "`-' ✓1..E
Well Permit Paid (� �VELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab r7/3/9� ��L
Public Replacement Air Vent
Site Approved_i / D`7/3�9 � Required Well Log �l�/Q`���
Well Head Approved Well Tag
Grouting Approved 7 g
Comments:
Date'7/3/9 � Installed by �NKI.N (,�,`lf:.�in��-APProved by
This report is based in part on iaformation provided the homeowner or his/her
representative in the applicatioa 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:lamipro�permit.sam O1/95 rev.l.l
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PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date:�30� '
Owner: � �
Location/Directions: —
SR#
Subdi�»��on Name: Lut �
Drilling Contractor: ��K�N uull� �M Sc�U T.N �
WELI, CONSTRUC'I'ION
Distance from Nearest Properry Line Distance from Source of
Pollution
Tota1 Dep.th:_ Ft. Yield: � GPM Static Water Level Ft.
Water Bearing Zones: Depth t. F� F� Ft.
Casing: Depth�: From d to Ft. Diameter: � Inches
TYPE: Steel � Galvanized Steel ✓
If Steel, does owner approve: Yes . No
� Weight: � Thickness: •� Height Above Ground: Inches
Drive Shoe: Yes No . � i
Were Problems Encountered in Setting the Casing? Yes No
If "ycs" give rcason:
Grout: Type: Neat Sand/Cement Concre[e '
Aruiular. Space Width � Z. Inches
Water in Annular Space: Yes No
._ Method: Pumped � Pressure Poured �� �
D�pth: From O to 2� Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes '� No � �
4 x 4 slab Yes ✓ No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION TS CORRECT AND THAT
THTS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON COUNTY HEALTH DEPARTMENT.
.
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Signature of Contract � Datc
i
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: � �� .=IMI'ROVEMENT PERMIT #: I �
Tp�{ Mpp #; PARCEL #: � Q �
OWNER/OWNER'S REPRESENTATIVE: I�►'Gl< ,/I/I C /C��e �
LOCATION/ADDRESS:
�� c�2 �
SUBDIVISION NAME:
SECTION OR BLOCK:
AUTHORIZATION FOR
� �P�11��� ��
ISSUED BY:
AUTHORIZATION CONDITIONS
LOT #:
l. The Wastewater system construction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Pernut #,�/� %3 The
constn.iction and installation must also meet al[ applicable ruies and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any alterations in site or soil conditions (including structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authorization and associated permits.
4. Conditions:
Permit written to allow the a��r,.t�t' Pl�c.�iFdK GJ �
4
with no change or addition to the existing septic svstem
Person Requesting:
� cr� �a� �i���s �� �.�,�o i�C3 � ���