A40 171. �
' �i�e �val�uatSon Application Date: t0 '�" 9 3
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�� Fee Collected YES •� NO
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G'�APPLICATION FOR IMPROVEMENTS PII2HIT
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1. Permit requested by: owner/prospective owner: � g w,�c`� C C
agent:
Address: (o y�-
Home Phone ��:
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2. Name and address of current owner: ?AcK_p �
3. Property Description: Lot size: 'y. (p,� /aC.,�'� �
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4. Tax map ��: � � 0 Township: �j ��� �jj�r�
Subdivision Name: Lot ��:
S. Directions to property: State 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: 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?
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10. Water supply private? public? community? spring? .,�
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Other source? (Specify):
Are there any wells on adjoining property? If so, identify location: �
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Type of structure or facility• Proposed: ✓ Existing:
Type of dwelling: House: � Mobile Home: Business:
Type of business: Number of Employees:
Number of bedrooms: y Garbage Disposal? Yes No ✓
Basement? Yes ✓ No If so, number of basement fixtures: /
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 uthorized Agent
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Permit Issued � �
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Permit Denied / '`
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rACTORS - SITE EVALUATION AREA 1 AREA 2 AREA 3 AREA 4
1. SLOPE (X)
2. SGIL TEXTURE (i2-36 in.)
(Sandy, Ioamy, clayey,
Note 2:1 clay)
�3 SOIL STRUCTUILE (12-36 in.)
(Clayey soils)
4 • SOIL DEPTH (in. ) '
5. RESTRICTZVE HORIZONS (in.)
(Iu�ervious Strata, rock)
6. SOIL DRAI2IAGE/GROUNDWATER
(bcternal & Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
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g. SITE CLASSIFICATION � � � j
(See below) �-�
SOIL SERIES
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R ECOMMEENDATIONS / COt�II fEriTS :
��TE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines. roads, streams, gullies,
aet areas, fill areas, wells, water bodies, slope patterns, etc.)
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A 1286
"�.�"'" PERSON COUNTY HEALTH DEPARTMENT
' �� ��� WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT ��� j� � jf
����' Tax Map # �{ � Parcel #
���� 1 � Zoning Townshi�
��/� Owner/Contractor � � � E i�y e _ -
� � Location/Address a5 T [... � �Q.v `5 � Lof' an �.� 139�
,� �F� _ S.R.#
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Subdivision Name ` Lot# Ay b�
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area U �(o `� Size of Tank
SFD 1/ Mobile Home Size of Pump Tank �A
Business # of Bedrooms_�_ Nitrification Line 1-t� � jC 3'
Max Depth Trenches a- �l ��
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site ' tered or intend e chan ed.
Well and Septic Layo t by
Comments: ..�C%1 �1 l��-� � � _
Date�' — Installed by �i ��-�-�o. Approved by W.,c:?� .� ��,
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WELL SYSTEM SPECIFICATIONS
Individual �/ Semi-Public
Public Replacement
Site Approved ✓
Well Head Approved
... . . . . .,� , _ ,.
Comments:
Required Slab 3r3 �- ro --9 9
Air Vent -�
Required Welj-Lon
Well Tag �� ' - �
7�J i� LO -i - g 5
(-9 3�-�,,�.-�
Date �� -[ " 9�i Installed by%jn.v�.�m �t ��r�N�'!1 Approved by
Tlus report is based in part on infonnation provided the homeowner or his/her representative in the applicatio ubmitted for this pemut The
environmental health specialist is not responsible for false or misleading infonnation 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 apptication. Neither Person County nor the environmental health specialist watrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�pemvtsam Ol/95 rev.1.0
ORIGINAL
. � � _�
' � :
P�RSON COUNTY ENVIRONMENTAL H�ALTH
WELL LOG
3--z� - �� ' � sR# �
Date:_ (��t� � � �("j' � .
Qwne�.
I,ocati�r,/Dixections: � .
r . 11
LVL T:�
Subdivision Namc: . � �ry � i�.� + � �.M � �
Drilling Cbntractor: ��N���ON_
Distancc from Ncarest :Property Lin� —
'D�stancc from Source of
Pollution � Z (�,pM Static Water Level FG
Total?�epzh: ._. F� Yield: . F� F�� �t.
Wacer Beacing Zones:`_ De�th Ft - / Ynches
Casing: Depth: From_._.._—to Ft• Diame �
�I'YPE: Steel ' Gal�anizEd Steel
If Steel, does owner approve: Y�s No____._�
' Height Above Ground:_______Ynches
. � Weight: 1'hickness: • ,
Drivc Shoe: Ycs _ No _ • --
Were Problems Encountered in SetZinS the Casing? Y�=""—_ No'
Ii "ycs" givc rcason: S�dJCement__ Concrete
Grout: Type: Neat � �_�lchcs
Annular. space wiath No+_
Water in Ar�ulat Spacc: Yes_ Poured •_=,..__ �.
Method: Pumped� Ftessure______
� Depth: From _� to O F� .
Materials Used: No. Bags Portland Cement-----
We�ght of 1 bag_...._lbs.
avel; cuttings) - Ratio: to � .
Yf mixture (sand, gr •
ID Platcs: Ycs '� No ..�
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I HEREBY CERTIFY THAT THE ABOVEINFORMr1'I'I��N�ITH REGULA ONS SE'T
THIS WELL WAS CONSTRUCTED 1N ACCOR E�TMENT. �
FOR'rH BY THE PERSON COUN'Y'Y HEAL'Y'H D .
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Signarirc of Contract � � Datc