HomeMy WebLinkAbout4030 US 42 SDELAWARE COUNTY HEALTH DEPARTMENT
IM N. Sandusky Street 614 368-1700 Delaware, Ohio 97015
APPLICATION FOR PERMIT TO INSTALL .�, l
HOUSEHOLD SEWAGE DISPOSAL SYSTEM PennN Nois2 ,o 1OL
Property owner — _ uN s , phoncz,151 -369—r//0 %
hereby applies for a permit to install e>nt na or modify a household a e tlisposal
:system located m HW3o 45 gin 12 Sou 2'1 in
HOuse Number Street Township
Iia.LAfildke' p 3/30/S on lot number
Yllage, iry, /, Zlp Subdivision/Lot M
Installer or Contractor LVA Vr ��AAGm✓eR
I agrea,o construct and Install Me households wage disposal system in accomance with regulation 101-121
of the Delaware City/Courdy Department of Hoorn end the approved plans. I have received an Irdrprmefion
of Mese name and regulations and underssM the provisions contained thenen.
I further agree that I will call for the Med Inspection and approval of the Delaware City/County Deprtmant of
HWM L fine installation m least twenty-four (24) hours in advance of as being cavred with earth and at least
Iw"4 he (24) hours in advance of as being placed in operation.
4 i to be understood that no system can be guaranteed because of 6011 Mrectedatics, onry workmanship Is
consideed at time of Ms Anal Inspection.
INSTALLATION PERMIT E)IPIRES ONE YEAR FROM DATE OF ISSUE.
__ OFFICE USE ONLY o
Applica
t Signe Penni[ Issued �% /dam_
House lumber/Street
lG,.,e/i Fee Paid n2
Towner 1p, 1 age, City p Receipt
��➢-3G2/—i�/C7 ��y6 Clerk
Phone Date &bignerure
The plm plan required by Mls regulation maybe proposed on Me noose side. The plan shall camaln Me
following:
(1) l he shape rW dimensions of Me for with the location of lot Knee bodes of water, ditches, Men tis and
.II easements.
12) the size, location and construction of Me proposed household sewage disposal system.
3 1 he location of all seat" supplies wdlen W feet of any component of the household sewage disposal
system on this or adI'acent loft.
(4) 1 he location of Me tlwalling units and bedrooms awed by this system.
-------------------------------
orsca use ONLY
Permit Approved Sl /R/9Io Disa F(WAKI
sanaahn Ae� DW
Final lmpeclion Approved
nature
Disapproved _�
senMn�.n
Ilea 1W. Code'. lazouan. 13212
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DELAWARE COUNTY HEALTH DEPARTMENT Appointment Date i6It, Time 11.E
109 N. SANDVSEY ST. - DELAWARE OH 0015 Ondine Feeaid��aceipt#
(610)36&1]00.510-7055
SEWAGE ONSITE EVALUATION FOEM
Peron Requesting Onsite: C.AWC0 /4%" s Phone: 36e- 410?
PROPERTY WO TION )�
House #:_ Streen 'TnJSlint
O ( S Townships (fox 'ORL
Lot #: Subdivision:
Directions to site:
SOUS
Soil Type #1: i✓rafL Y Symb. A/B % Slope: �J'/. Depth of Badmen _
Seasonal H2O Tab:_ Fn®pan?_ Wooded? ,uL. Sheet #: 3 Perm:_
Solt Type #2: 1�tb.uT Symb. B/p % Slope:0_i Depth of Bedrock: '>S I
Seasonal H2O Tab:_ Fra®pan?_ Wooded? No Sheet #: 33 Penn:_
DWELWNG #Bedrooms:iii Basement? 4LL Plbg. below grade? -00
CONCLUSIONS Site is suimble? [.]'Yes [ ] No Conditions:
TAPE OF SYSTEM RECOMMENDED
Septic and leach system consistingof(I)aM�gal. septic tank(s);9te> Linear feet of leaching tile in two
equal fields; curtain drain [-Mes [ ] No; Bad up)Secondary leaching field area.
Class I NSF App. St. Q Aeration system processing _ gal. wmerlday.
_ Sq. B. subsurfa¢ sand filter.
Chlorinator
Engineered Mound System
Other
WATER SYSTEM
Well _ Cistern _ Hauled water storage tank _ Pond _ Spring _ Usdng? _ New? luxo
Onsite Done By: Sts. Date: &/i %
941 qG
a h
2
M
See Reverse Side For Further Instructions :Tjq
• y,, � and
ASSOCIATES, _
STULTSandINC.
AHCMMCTS+EN VEERS
Y•SURVEYORS
^x`Yti.Yh'
PLAT OF SPLIT OF LOT NO. 4271 OF JA -BON SUISDIVIS:ON ANO THE
VACATION OF TWO (Z) EASEMENTS
Situated in Concord Township, Delaware County, Ohio,
and being part
Of Farm Lot 5, SeCtiOn 4, Township 4, Range 20,
United States
Military Lands.
JA -BON SUBDIVISION
EXHIBIT 'B
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LEGENO
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r4271AND 4272 ARE ED
TO IN CASCMENT i DEL CO P� WC
�yyE DR �wE 1puxD
APPLICATION POR VARIANCE REQUEST
To Applicant: The following information is requested t0 consider a
variants to Delaware city/County Board of Health rules and or
Policy. Once submitted it will be handled as a public document of
This agency, along with any supporting documentation that is
Submitted. This form must be received by the Health Commissioner
at least Ia days prior to the Board of Health meeting. However,
You must allow additional sufficient time for field review by the
agency sanitarian. The Board of Health may in some circumstances
authorize the Health commissioner or committee to review and
determine the action on this request. A site visit may be
conducted. You will receive a copy of this form when completed by
staff and it will Serve as your notice of inclusion on the
Committee/Board agenda for consideration on Ne date and time
indicated. You may attend such meeting(s) and provide additional
testimony on your behalf. Hearings are held at the Health
Department office at 109 N Sandusky St., Delaware, Ohio.
Applicant: L'A'q tai — ?44a/1'-.(/5
Check One: [N Owner [ j Contractor [ ] Developer
current Address: y/I yO ii C LY.? 01 c
he/a sac n
Phony.
Property in Question:
Address: 030 1 .S
Township/Village: O
A. If this is in regard to a variance on water/sewage/plumbing
indicate:
1. Name Of subdivision:
za. Date Subdivision was recorded:
b. If not known, was this prior to 1976 1978
1984 1989
9. Describe lot size, dimensions, easements, nearby stream
Include a sketch if possible:
g-r>An�PO
a. Indicate the number of bedrooms in the home and intended
number of residents: 3edvjEVo J — 3 02pgoze
B. Describe the variance requested and the reason for the
request. (Include reasons of hardship and why you can not
comply with the IBw/TBIOB/Policies of the department.)
LOT mem P25 .99/
C. List all adjoining property owners or persona who would be
affected by the granting of Chis request. Include sailing
Aldresses.
SANITARIAN REVIEW
A. List the program and rules number(s) for which there is a
variance request: `` li
B. Indicate the policy for which a variance is requested:
C. Indicate the circumstances leadinq up to this request.
including InvOlv8Mant of other local or State agencies.
Mention nusualmstances such as flood Plains,
e*oarimental systems, unforeseen geological problems, etc.
TMa. It. AC
D. If water eewaq lumbing, discuss resulte. of field observation
of the pr y. notinq whether the laws/rules/policies could
be followed:
Rdor 11 T
-
E. Would granting such ean enc e be in keeping with the spirit
and _intent of rules? N 1�
___________________________________________________M1 25700/
HEALTH COMMISSIONER REVIEW/ACTION
SCheculed for Committee meeting on
Scheduled for Board of Health meeting on
Variance: ___ Approved _.-_ Denied ,— Penning Action
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