A41 11 (2)- ..�
Additional appliances to be used: Disposal, dishwasher, washing
machine LL�' ./ � { �'
Recommended• Septic tanl � ��'� �� � %� � � �
Nitrification line: -���( � , C� I
Above recommendation based on information received and observed
soil condition. Sentic tank and nitrification line must be inspecfed and
approved by a member of ihe Districf Health Department siaff before
any portion of the installation is covered.
Date Approved: � �--� ��- �.� �)
By:_
-
Signe�
� � Sanitarian
:��l.Z �� i-/ �f �..'�),
Countersigned
O. David Garvin, M.D., M.P.H.
District Health Officer
(Over)
r
0
NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on
adjacent property, etc. Write in measurements in order that installations may be located at later
date.
SUGGESTED INSTALLATION (Date ) FINAL INSTALLATION (Date )
(ftoad or Street) (Road or Street)
.,
PERSON COUNTY HEALTH DEPARTMENT
LL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
Tax Map # �/ � / Parcel # � %
Owner/Contractor
Location/Address
Township �.��,j� p�-�.
�— DateS- �- �s'
A 0�19
,�YvuC.� � �=�� �-vH-u �°I. ` S.-R`.# /t�-��. /.�'%��.�ti
Subd- ivision Name N/,� Lot# Il/j�$ �
.
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SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area �,.SQ��ay Siae of Tank /�� ' �_
SFD �/' Mobile Home Size of Pump Tank_ Ni'�¢
Business # of Bedrooms ,3 Nitrification Line �� ,e SSD/ � `
Max Depth Trenches �
Permit Void after 60 months. Pernut Void if not in compllance with zoning regulations.
Permits may be voided if site is altered or intended use changed.
Well and Septic Layout by '' )�,t�� �
Comments: �
DateS- �3� �',S' Installed by ' Approved by �.�.� ��.�,,�
te Approved.
ell Head Au1
Date
WELL S
_Semi-Public_
Replacement
Installed
SPECIFICA'
Required Slab
Air Vent
Required W 1 Lo�
Well Tag
Approved by.
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this peimi� The
enduonmental health specialist is not responsible for false or misleading infonnation contained in the application. The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in this repoR that may have resulted from false or misleading
statements provided to him in the application. Neither Person County nor the envuonmental health specialist warrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply wiil remain potable. c:\amipto�pemutsam O1/95 rev.1.0
ORIGINAL