A40 176! �._,�6
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, (. Improvement Permit
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APPLICATION FaR:
( ) �Subdivision
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Date Receivea • �j � /�'� �/
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( Other � �,,
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1. Permit re uested by: a�(/l.{�{'(, -, TL � Home Phone � �
' "� " Address: � �`�. Ord �C� S—'7 Business Phone�
2. Name and address of current owner: ���U� G���1� �-�-• �( 13r:� y3s �
3. Property. Description: Lot size ���Z r�-cr. Dimensions:
Front � � ac�� Left 50 -Ft • Right �Sb -�-(. Rear ib -
4. Tax map No. Township: ��QI 1'I �ii� Block No. Lot No.
5. Directions to property: State Road No. & Ro d Names, etc.
l I �/ �- v1 akn_c,,i� �6�c,.,,���� �,�u.i�-z�L �'��
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6. PArmit requested for: New Installation V Repaired
Additional Renovation re-using present system
7. Number of occupants of people served�
8. Dimensions of Proposed Structure: Width Depth �.,� �5�
9. What tyge (if any) additions, expansions, or�replacement is an�icipated
te the structure or facility that this sewage disposal sys�em is intend
to serve?
10.
il.
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.
Type of structure or facility: Proposed Existing �
Type of dwelling: House Mobile Hom� Business
Type of business /� Number of EmploXees
Number of Bedrooms� Number of automatic appliances
Basement /� !%q- Number of basement fixtures
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12. Clearly stake sll corners of the property and the corners of all p
structures.
I hereby make application to the Person County Iiealth 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
placed on the property. I understand that if any changes are made without
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
Person County H�alth Department. Permits are valid for 6e months from dat
of issue.
�
SIGNED
FACTORS - SITE EVALUATION
1. SLOPE (X)
2. SOIL TEXTURE (12-36 in.)
(Sandy, loamy, clayey,
Note 2:1 clay)
3. SOIL STRUCT(1RE (12-36 in.
(Clayey soils) �
4. SOIL DEPTH (in.)
5. RESTRICTIVE HORIZONS (in.
(Impervious Strata, rock)
6. SOIL DRAINAGE/GROUNDWATER
(bcternal � Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
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9. SITE CLASSIFICATION
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
RECO�NDATIONS/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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Amount paid� �__�
R:eceipt 11 lU8 1 L
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�rmit requested by: . �, P��
owner/prospective owner/agent: ��
Address: �� � -��"�� �� �� 7
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ome Phone #: ��� � -
usiness Phone #: .2�''J 'a 66,2 �i�, S.3a�
Name and address of currenc owner: _
5�5'°� (xc �u ?A,�l�e,+�'v� '
ezc�o � iv �C• a-'1 S� 3
Propercy Description: L.oc size: ' �
Tax Map#: � � v
Parcel#: � � 7
Township:- ���A�' (���e ? ,�
. Directions.to property: State Road #& Road
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Lead
7. imension� �rop� ed Structur . /J-�s�
W idth: a� s
Depth:
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8. What type (if any, additions, expansions, or ��
replacemenc is anticipated to the stn�cture or facility
� that this sewage disposal system is�-intended to serve?
9. W ater su t} pe:
privat .public❑ community❑ spring❑
Are any wells on adjoining property?Yes C✓7 I`lo Q
�If so, identify location:
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. Type of structurelfacility: Froposed: �Existing: Q�
ype of dwelling: i
House: ❑ Mobile Home: L�Business: ❑ �
Type of business: '
I�Iumber of Employees: _
Number of bedrooms: y
Garbage Disposal? Yes 0 No � �.
Basement? Yes❑ No�'If so, # of basement fixtures:
6. I�Iumber of occupants or people to be served:
CLEARI�Y STAKE ALL CORNERS OF THE PktOPERTY AND THE CORI`IER� 0� ALL
PROPOSED STRUCTURES• -
I hereby make application to the PeI'SOn C011IIty T�ealt�l DePax�lent for a site evaluation for the on-si:�
sewage disposal system for the above described property. I agree that the concencs of this application are crue
.� 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 Z hat in the etv nc have nc ,
issued, I must pcesent a survey plat of the property to the Healch Dep� I understand c
delivered a survey plal of lhe property to•lhe Health Dept. wichin 60 AAYS after the date of the evaluation of
the site by the I-Iealth Dept., this application shall become vottf and all fees paid forfeited.
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,e�ni,[ Issued•❑ . Signature _
�ermit Denied 0
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RECOMMENDATIONS/COMMENTS: '
SITE CLASSIFICATION DIAGRA.M.(Include: Soil areas, property lines, roads,streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.) C.1AMtPRd.DOCMPPSEC.S1�1 FINANCEPC
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� B 1841
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION Il�'ROVEMENT 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. �
.
T� Mar # p�� O Parcel # � 7� 1% d% a`�.,� —���
Zoning Township �( at R� ve�'
Owner/Contractor � l a.dv s k-F p'i e�rc e Date 8( d o� 97
Location/Address �,J a� N� t 5 � C 5 af RoY �o o�n) o., }�a.y v►es TG-u e� n Rd � D, 5s
v�n.i. o►� P'-E- � Lo-4- �, S.R.# I I�-I o1
Subdivision Name Lot# q
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area d� (o Size of Tank > l, UOd
SFD �� Mobile Home ' Size of Pump Tank
Business # of Bedrooms� Nitrification Line ;� S ee d:a �a.K
Max Depth Trenches �'� �N � a�'r
Permits may be voided if site is
Well and Septic Layout by
Comments: / ! f�e.�
%.t u��'s �{ur�ie d Sai /,
ged.
� . ; fr�i■�i,ir - � � ', � �� • � �' : -'•7 � r�L��j�
�!'���'-'._--_: �� I!_�.–�i��.�%:���-J�� "�' _..�s -
-�si+r� �� - ��� — —
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Individual ✓ Semi-Public
Public Replacement_
Site Approved �/
Well Head Approved
Grouting Approved / � — 6 " �
Comments:
j,C! r
Required Slab t/� ``�"�
Air Vent �- 9
Required Well Log �/
Well Tag ✓�
Date ,,3 �— Installed by Gu.�e �o, Approved by .�C�,t�
This report is based in part on information 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
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IMPROVEMENT PERMI T DIAGRAM
Gladys H. Pierce Tax Map#A40 Parcel 176
,rni�-ial 5�5i-em �t�a.;Kf;�1�
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�� Si G4tdn�btf: D'�-Gild�c�Oer �
S� Sto,K �sc�eral b�u►,as
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O�Oai labte�
50.00 feet
1:160
108.00 feet `
N 9° 26• 27'E `
Lot A 0.68 ac.
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124.43 feet
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Jeff Dillard, R.S.
Environmental Health Specialist
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PERSON COUNTY ENVIRONMEKTAL HEALTH
WELL LOG
Date:�/•l� =Q7 '
Owner. � 1 , s
Location/Directions: _
' !a l e "
Subdivision �N�un :
Drilling Contractor: �
WELL CONSTRUCq'ION --
Dist�ance from Nearest Property Line /b Distance from Source of
Pollution____�C�� '
Total De�th: Do Ft. Yield: 7sj GPM Static Water Level a__ S___Ft.
Wa[er Bearing Zones: Depth �Ft. Ft� Ft� �t,
Casing: Depth: From�_to�o Ft. Diameter:l 'ly Inches
TYPE: Steel - Galvanized Steel �
If Steel, does owner approve: Yes No
� Weight: Thickness: f1� Height�Above Ground: l�l Inches
Drive Shoe: Yes � No -
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" give reason:
Grout: Type: Neat Sand/Cement_ � Concrete
Annular. Space Width Inches
Water in Annular Space: Yes No
_ .. Method: Pumped . _ . �Pr:ssure - . � Poured � ... . . . ,, - � -
Depth: From_ �l to ao Ft. � � _
MateriaLs Used: No. Bags Portland Cement Weight of .1 bag__lbs.
If mixture (sand, gravel; cuttings) - Ratio: 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 C�Ui�ITY HEALTH DEPARTMENT. �
;��� ����0 ---
�Signature of Contractor Date
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