A35 153� �`Site Evaluation Application
Fee Collected YES �
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1. Permit requested by:
Address: �
Home Phone ��:
Date : � , �•- 9 �
NO
APPLICATION FOR IMPROVEMENTS PERHIT
�/prospective owner: o�r,,,� S �e '�''
�J b,.� �� V`aoe� `�o J` v _�,�
as �// Business Phone �r`:
2. Name and address of current owner: � cx-e 1 1 ��� \'e
� � Y�oV' O � � � � � - ----
3. Property Description: Lot size: � a� c v'r S
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4. Tax map ��: Township:
,'Subdivision Name:
S. Directions to property: Sta�t/�e Road �� & Road Names, etc.
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6. Permit requested for: New Installation: � Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served: �
8. Dimensions of Proposed Structure: Width: :zk' (� Depth:
9. What type (if any) additions, expansions, or replacement is anticipated to the struc-
ture or facility that t is sewage sposal system is inten�ded � serve?
�'� c.�n.� �_ �0 �S 5 � �.�'� �Vv�cs����k��rSc o� o� eC .
10.
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Water supply private? � public? community? spring?
Other source? �Specify):
Are there any wells on adjoining property? If so, identify location:
�y
N
X
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Type of structure or facility: Proposed: � Ex�st'ing:
.-
Type of dwelling: House: Mobile Home:� -�''� Business:
Type of business: ''� ` Number of Employees:
Number of bedrooms: Garbage Disposal? Yes...- No 1/
Basement? Yes No, If so, number of basement�fixtures:
.. ':�.�
Clearly stake all corners of the property and the corners of all proposed structures•I
I hereby make application to the Person County HealtY� Dep�artment for a site
evaluation or existing system evaluation for the on-�si"Ce""-se''�a`a"ge 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.
Permits are valid for 60 months from date of issue. Permission is hereby granted to
enter the property for the evaluation. G.S. 130A-335(F)
" ed Owner or Authori2eci Agent
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Permit Issued
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Permit Denied
Plat Observed
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i�ACTORS — SITE EVALUATION AREA 1 AREA 2 ARFA 3 ARF.A 4
1. SLOPE �X)
2 . SaII. TExTURE (12-36 i.n. )
(Sandy, Ioamy, clayey,
Note 2:1 clay)
�3 SOIL STRUCTURE (12-36 in.
(Clayey soils)
4 . SOIL DEPTH (a.n. )
5. RESTRICTIVE HORIZONS (in.
(Impervious Strata, rock)
6. SOIL DRAIIZAGE/GROUNDWATER
(FScternal � Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
$. OTHER (specify)
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9. SITE CLASSIFICATION ' �� ��� � )S
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECOF4fEI1DATI0NS /COI�iEriTS :
S1TE CLASSIFICATION DIAGRAM (Include: Soil areas, praperty lines. roads, streams, gullies,
aet areas, fill areas, wells, water bodies, slope patterns, etc.)
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� ��•-- - `� PERSON COUNTY HEALTH DEPARTMENT • - - .
WELL AlVD SEWAGE SITE, LOCATION IlVIPROVEMENT PERNIIT
Tax Map # � 3�� Parcel # � S 3
Zoning Township
mi
Owner/Contractor �
Loc tion/Address -/✓,-
' ��Pi� G�
ubdivision Name
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Date _ ! = �
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`,� ' S.R.# /�
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(��� yout � Install �—� j �` 1
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SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area � �� Size of Tank�o < S.
SFD Mobile Home �/ Size of Pump Tank�
Business # of Bedrooms_,,3_ Nitrification Line �
Max Depth Trenches � b' +
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is al d in nd use chan ed.
Well an� Septic Layout by
Comments:
Date
Site Approved
Well Head Approved
Grouting Approved_
Comments:
WELL SYSTEM SPECIFICATIONS
Semi-Public Required Slab l/ j}��
,
Zeplace nt Air Vent
Required Well Lo� ✓
Well Tag ,/
Date --' Installed by /Vla�t,�15, Approved by �
This report is based in part on Wormation provided the homeowner or his/her representative in the applicat submitted for this permit The
environmental health specialist is not responsible for false or misleading infotmation 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 Pecson County nor the envuonmental health specialist wazrants 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.1.0
ORIGINAL
�_ . . ' ' � . . 1
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date: " ��
Owner: _�T
Location/Directions: _
SR#
C'..l�r�=..:n: r�. �Tilmn� ' � - „
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Drilling Contractor: �i .��s Ls��-�, �' c,
WELL, CONSTRUC'I'ION
Distance from Nearest Property Line fo� y�'f- Distance from ��urce of
Pollution fbti '�'f"'
Total Dep.th: / SO Ft. Yield: S GPM Static Water Level /o o Ft.
Water Bearing Zones: Depth O Ft._ ,�Ta Ft. /�s'hFt: Ft.
Casing: Depth: From o to��Ft. Diameter: � Inches
TYPE: Steel - Galvanizeci Steel ��.s
If Steel, does owner approve: Yes c/ No
Weight: Thickness: / SS� Height:Above Ground:� �� Inches
Drive Shoe: Yes � No
Were Problems Encountered in Setting the Casing? Yes No ✓
Tf "ycs" �ive reason:
Grout: Type: Neat Sand/Cement Coricrete
Annular Space Widch Inches /
Water in Annular Space: Yes No ✓
Method: PL.mped Pr�:,sure - Pou.re;d ��
Denth' F£C�??? /�� IQ ,�_ O ;�i.
Materials Used: No. Bags Portland Cement_� tiYeight of 1 ba���lbs.
If mixture (sand, gravel, cuttings) - Ratio: z to
ID Plates: Yes �-� No
4 x 4 slab Yes ✓ No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON COUN'TY HEALTH DEPARTMENT'.
l�'%-i�
ignature of Contractor Date
Mar 01 17 02:44p Barnette Well Drillinglnc
WELL GONSTRIIETiDN REC
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Barnette Wel! Drilling, M c.
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