A40 162� Person County Heaith Department
Sewage System Improvements Permit
Date: " 3" � Th�s e't Void After 5 Y s
Owner: ' � , �R# ���
Location/Directians: � , � 4 r`' I ►
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Subdivision Name: s Lot #
Lot Size: �.��� Type of Dwelling:
Water Supply: Privatc: Public: Community:
Bedrooms: �_ Garbage Disposal
Basement Basement Fixtures
INFORMA C T D/�Y
Sanitarian: JS owTer or representative
REPAIR: REEVALUATION:
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Size of Septic Tank: gallor�s Size of Pump Tank:
Nitrification Line: �
Depth of Stone: 12 inches
Ma�c Depth of Trenches:
Alternative System: Conv. Pump LPP Pump
Remazks:
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Date VVell Approved: Well should be 100 f� from any sewer system
BY Sanitarian
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BY� = � � Sanitarian
( CERTIFTCATE OF COMPLETION
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Sewage System location, installation, and protection must meet state and local '�
regulations. Septic tank should be pumped out every 3 to 5 years and shall be maintained �
by owner in such manner as not to create a public health hazard. Septic tank and'd
nitrification line must be inspected and approved by a member of the Person Counry �
Health Department before any portion of the installation is covered and put into use. If
the site plans or intended use change this permi[ is subject to revocadon.
(G.S.130 A-335F)
I.ocation of sewage disposal sewage system sketched on back. C
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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.
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� ( ) Improvement Permit
APPLICATION FOR:
(� Subdivision
1. Permit reg�e ted by: `�Y/ �
Address: /l�u,�� �L� . Z l
2. Name and address of current owner:
Date Received: i -�� 91
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( ) Other �
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����Home Phone 5 �
i Business Phone
3. Property Descriptione Lot size 3 � 3� Dimensions:
Front Left Right Rear
4. Tax map No./��D 14+0� Township: Block No.
5. Directions to p p r/� y: tate Road No. & Road Names, etc.
�/I�rA I%7`l ���//S �a�� � __ --
Lot No. �
6. Psrmit requested for: New Installation Repaired
Additional Renovation re-using present system
7. Number of occupants o£ people served
8. Dimensions of Proposed Structure: Width Depth
9. What type (if any) additions, expansions, or�replac�*nent is ani.icipated
to the structure or facility that this sewage disposal sys#.em is intend
to serve?
.10. Type of water supply: Well " yes no: If no, name source of water
supply: Are there any wells on adjoining
property? If so, identify location.
11. Type of structure or facilit-y: Proposed Existing
Type of dwelling: House°� Mobile Home Business
Type of business Number of Employees
Number of Bedrooms Number of automatic appliances
Basement Number of basement fixtures
12. Clearly stake all corners of the property snd the corners�of all proposed
structures.
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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 conten
of this application are true and represent the maximum facilities to be b
placed on the property. I understand that if any changes are made without h
approval from the Person County Health Department, the permit will be void. �.
Any permit for a system is non-transferable without prior approval of the `t
Person County H�alth Department. Permits are valid for 6e months from dat �
of issue. �
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r�acTORS - SITE EVALUATION
1. SLOPE (X)
2. SOIL TEXTURE (12-36 in.)
(Sandy, loamy, clayey,
Note 2:I clay)
3. SOIL STRUCTURE (12-36 in.
(Clayey soils) �
4. SOIL DEPTH (in.)
S. RESTRICTIVE HORIZONS (in.
(Impervious Strata, rock)
6. SOIL DRAINAGE/GROUNDWATER
(External � Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
AREA
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' AREA 2
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AREA 3
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P5
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8. OTHER (specify) PS PS PS " PS
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9. SITE CLASSIFICATION --
(See below) �
SOIL SERIES --
S- Suitable PS - Provisionally Suitable U- Unsuitable
RECOMMENDATIONS/COMMENTS.
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies,
wet areas, fill.areas, wells, water bodies, slope patterns, etc.)
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AREA 4
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