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A35 103� " �� i, Person County Health Department Sewage System Improvements Permit Date�^�'�is Permit Void After 5 Years "'�f Owner: SR# 3S Location/Directions: _ ��n m v,� r.,� _� e,=,. P.. �+� n . Subdivision Name: � � Lot Size: �- n c�- �'�- Type of Dwelling: Water. Supply: Private: � '�' Public: Beclrooms: 3 Gazbage Disposal Basement Basement Fixtures iNFORMAP�N�EbtTIFniED BY . t� oµner or REPAIR: - - REEVALUATION: ' I I.�t # Community: �� — C .,� .a� ,� . ��a..��.., _ S Size of Septic Tank: /Q� gallons Size of Pump Tank: Nitri�cation Line: �2( �� ' Depth of Stone: 12 inches Max Depth of Trenches: Altemative System: Conv. Pump LPP Pump Remarks: ------------------------- Date Well Approved: 3= �� 4 Well should be 100 f� from any sewer system BY Sanitarian Date Sewage System Approved: 3-13 -�j G BY�J �%� d9 -«�-- Sanitarian CERTI�iCATE OF COMPLETION Contractor. ,�✓�-�c ------------------------- � Sewage System location, installation, and protection must meet state and local '� regulations. Sepdc tank should be pumped out every 3 to 5 years and shall be maintained � by ownei in: such manner as not to creaie a public health hazazd. Septic tank and'� nitrification line must be inspected and approved by a member of the Person County � Health Deparunent before any portion of the installation is covered and put into use. If the site plans or intended use change this pernut is subject to revocation. (G.S. 130 A-335F) L.ocation of sewage disposal sewage system sketched on back. (OVER) � /'„ � W I�� %�� 1!`t! ✓ iL � i � NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located at later date: Note location of water supplies on adjacent lots. �� \ �`/ �. �. 13 3 s �, � Parson County Heal£h Department well Permit DATE ISS,U�',D: • OWNERs V � � ADDRESS� DRILLING CONTRACTOR: DRILLED: '��kOUNTY: C/' � ROAD/STREET��, WELL CONSTRUCTION Distance from Nearest Property Lina1�Distance from Source of Pollution /n Q �/,,,.s \ Total Depthf J_]..� . Yield: (J GPM Static Water Level Ft. Flater Bearing Zones: De th Ft �.S' Ft. Ft. Pt. Casing: Depth: From�to Y Ft. Diameter:��Inches TYPE: Steel Galvani ed Steel 4� If Steel, does owner approve: Yes No Weight:�Thick,n'esssl �YHeight Above Groundi��/ZnChes Drive Shoe: Yes No F►ere Problems Encountered in Settinq the Casinq? Yes_No_ If 'yes' give reason: Grout: Type: Neat 1� Sand/Cement Concreta Annular Space Width 3 Inches Water in Annular Space� Yes No c.i Method: Pumped� pressure Poured �. Depth: From to Ft. !laterials Uaedt No. Bags Port and Cement�wgight of 1 bag�lbs. If mixtur (aand, gravel, cuttings) - Ratio,_ �to�_ ID Platess Yes i� No � x d alab Yea—� Nu I HEREBY CERTIFY TH1►T THE ABOVE INFORMI►TZON IS CORAECT 11ND THAT TH2S WELL NAS CONSTRUCTED IN ACCORDANCE W7TH REGULATIONS SET £ORTH 8Y THE PERSON COUNTY BOARD UF HEALTH. pERMIT VOID AFTER THREE YEARS. _�/� 2�/�C/C� . z _ q Signature of Contractor Date Sanitarian's Signature Date Issued Seaitarian's Signature Date Canpleted Sketch well location on zeverae side. � w U � a ... Improvements Permit (Established/Recorded Lo[)�_ Reinspection of Existing System (Loan Closing) Improvements Permit (Unrecorded Lot) Improvements Permit (Mobile Home Replace) Permit (Addition) Repair/Replace existing Septic System Permit for New Well _ Replace Existing Well 1. Permit requested by: 7. Dimensions or� Proposed Structure: Y�l� u.. owner/prospective owner/agent: So�nn �K�i Width: ag S�� w�l, Address: !!! ��v� LN . Depth: !cb ome Phone #: 5qq - 3so S usiness Phone #: .�99 - S 7a3 Name and address of current owner: Description: Lot size: 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? 9. Wate�r su� ply t}•pe: � private Ly' public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No ❑ If so, identify location: . Tax Map#: 3� 10. Type of structure/facility: Proposed: �Existing: ❑ Parcel#: 4� Type of dwelling: Township: � ��b�� House: ❑ Mobile Home: �"usiness: ❑ � Type of business: ¢ 5. Directions to property: State Road #& Road Number of Employees: ames, etc. 3 � • j� L or. � E s ;� Number of bedrooms: � u� �� d t � f�rcv� vtT. Z�o�v Garbage Disposal? Yes ❑ No CC� H/'ilr, r�if �iJ /� ,,,, D� �� GnJ, Iast bR� veon 1� Basement? Yes ❑ No f� so, # of basement fixtures: W ¢ z 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 Pers0I1 COunty Health Depal'tment 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 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. .•• Permit Issued ❑ Signature Permit Denied ❑ Plat Observed ❑ Date _ _ ; . ; ..FXCTORS-SITEEVlII.ilA770N i ;? ,. � ,`ARP�St ;:; . ARFA2. .;;' `'AREPi3 `;AREA4 ':: 1. S[APE (%) S S S� S PS PS PS PS U U U U 2. SOILI'EX.TURE(I2•36IN.) S S S S (SANDY, LOAMY. CLAYEY. N07E 2:1 CLAY) PS PS PS PS U O D U 3. SOILSl7tUC7i1RE(12-361N.) S S ' S S (CLAYEY SO1LS) PS PS PS PS U U U U S. SOIL DEPIIi (C7.) S S S S PS PS PS PS U U U U S. RESTRICi1VEHORIZONS(IN.) S S S S (AIPERViOUS STRATA, ROCK) PS PS PS PS U U U U 6. SOQ. DRAINAG&GROl1NDWATER S S S S (FJRERNAL & INTERNAL) PS PS PS PS ' U U U U 7. SOIL PERMEABILITY S S S S (PERCOLOA'[ION RATE) PS PS PS PS U U U U 8. AVpILABLE SPACE S S S S PS PS PS PS , U U U U 9. SIiECLASS[F7CATION(SEEBELOR7 SOIL SER(ES SSUITADLE PS-PROVLSIONALLY SUITABLE U-UNSUII'AHLE RECOMMENDATIONS/COMMENTS: SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, s[reams, gullies, wet areas, fill areas, wells, water bodies, slope patterns, etc.� C:�AM[PRO�DOCSIAPPSECSM FINANCE.PC M O � a w U � a � B 0� 80 .,.- 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 # � ,7j,� Parcel # � i�� Zoning T�wnship o o c� S cZ Owner/Contractor � Date ��2-t'yG Location/Address i�� s+-� ' ' ' me� � P'�� e�� '°� _ __ e � S.R.# /�3.� �� f Subdivision Name _ Lot# Permits may be voided if site is alte r i en ed use changed. Well and Septic Layout by Comments: Date .�-I2-�� Installed by, Well Permit Paid ❑ ��VE: � Site roved � Well He pproved tmg Approved_ Comments: Date Installed by. Approved by SYSTEM SPECIFICATIONS i.�ent � �c}uired og Approved by. This report is based in part on infor�iation 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 O1/95 rev.l.l _ 'b s.j� �� r•w a�. r�' � / ; � � . � �; R � .� S eJ �� . , wf�•,,�,R � ~ F ''w9, .f � o, s ��s p. . ��'�� .�� ,, / ` � '�, � 6`09 �� _� �� w �� f,M - "1�. /�• j�:� . , . - �� i .� 1� ��-� � ,. f � _ ��``` ` � , -`_, ; �� ``_ \ `�.�N�I.\, r� a j� � �'''`' ~ �'�; , � -, � �� '-�-�� .� _ . 4_Y � � N oi,�� ' ; � :.;-: � � �� . :;:• � N� c�. �l� � rc- � - �� * ,; r.�i No,, . �b � C�� x�� -� , a"�ir �o'��'�' i,� . \� � Iroa�a�t 1�v�., � A�wlw /JI�� /ybrn-/�r� �MiM /� � : �9 �' e - m. ��0✓ ri . � �:.� L. �. G��/ . �� I ; ;