A40 115z
Person County Health Department �
Sewage System Imp,rovements Permit
Date: �3 This Permit Void After 5 Years Permit #� �
.
Owner: — SR# ��
Location/Direcdons: v P✓
Subdivision Name: S S J Lot #�_
Lot Size: Type of Dwelling:
Water Supply:�vate: —�� Public: Community:
Bedrooms: Garbage Disposal
Basement Basement Fixtures ;
INFORMATION CERTIFIED BY � �''�'�`'�-
Environmental Health Specialist: "'" r �
REPAIR: REEV UATIO :
Size of Septic Tank: �W allons Size � Pump Tank:
Nitrification Line: � 3
Depth of Stone: 12 inches
Max Depth of Trenches:
Alternative System: Conv. Pump LPP Pump
Remarks: ► 0 . � � e i n , / � � � �
�, � _
— — — �� � — �.��1 S� �� _ � ��'� � - ". -`
Date Well Approved: Well should be 100 f� from any sewer system
By Environmental Health Specialist
Date Sewage System Approved:
By Environmental Health Specialist
CERTIFICATE OF COMPLETTON
Contractor.
Sewage System location, installation, and protection must meet state and local
regulations. Septic tanlc should be pumped out every 3 to 5 yeazs and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and
nitrif'ication 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 permit is subject to revocation
(G.S. 130 A-335F)
L.ocakion of sewage disposal sewage system sketched on back.
(OVER)
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.
(1) (2)
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Site Evaluation Application Date: 3_ i�_ ��
Fee Collected YES � NO
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�°��,3-q3 �,� ��a�
� APPLICATIOId FOR IMPROVEMENTS PERHIT � �pG%OUS �r✓�'��Y
� � � aV''�Cr' �LL���e ��hnso��
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1. Permit requested by:
Address:
Home Phone ��:
prospective owner:
agent:
2. Name and address of current owner:
Business Phone �i:
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3. Property Description: L�t size: ���� G�
4. Tax map ��: Township: �/aq'�f�_C1J�;L�fd�cE,
Subdivision Name: ��/�,,�a�,L, �.r_�� /�- Lot �i�:
S. Directions to property: State Road �� & Road Names, etc.
� S � � �D � � �� �l u,��.�.c� �n 1 II.r r ,c �
�} 'rP n., t� A �Gf Gla.L / �� � 2;J� _
6. Permit requested for: New Installation: V Repair:
- Additional Renovation re-using present system:
7. Number of occupants or people to be served: �
8. Dimensions of Proposed Structure: Width:
Depth:
9. What type (if any) additions, expansions, or replacement is anticipated to the struc-
ture or facility that this sewage disposal system is intended to serve?
10.
11,
Water supply private? �/ public? _
Other source? (Specify):
Are there any wells on adjoining property?
community? spring?
If so, identify location:
Type of structure or facility: Proposed: Existing:
Type of dwelling: House: Mobile Home: �/ Business:
Type of business: Number of Employees: ,
Number of bedrooms: Garbage Disposal? Yes No
Basement? Yes No If so, number of basement fi?ctures:
12. Clearly stake all corners of the property and the corners of all proposed structures.
I hereby make application to the Person County Health Department for a site
evaluation or existing system 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.
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)
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Signed Owner or Authorizen Agent
Permit Issued ,�•
Permit Denied
Plat Observed �
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rACTORS — SITE EVALUATION
1. SLOPE (X)
2 . SOIL TEXTiTRE (i2-36 i.n. )
(Saudy, Ioamy, clayey,
Note 2:1 clay)
3. SOIL STRUCT[TRE (12-36 in.
(Clayey soils)
4. SOIL DEPTH (in.)
5. RESTRICTIVE HORIZONS (in.
(Zmpervious Strata, rock)
6. SOIL DRAI2IAGE/GROUNDWATER
(�cternal � Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
X-
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$. OTHER (specify) PS � � `
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9. SITE CLASSIFICATION � (
(See below) `�
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECO2�QiENDATIONS / COrR4IIdTS :
S?TE CLASSIFZCATION DLAGRAM (Include: Soil areas, property lines. roads, streams, gullies,
Wet areas, fill areas, c�ells. water bodies, slope patterns, etc.)