A40 179+ �erson County Heaith Department �
Weii Permit �
Date: -12'�� This Ee�init Void After 3 Years
Owner: f2 ��'�� (3 � s h �� SR# /S'I
Locadon/Directions: �� ' � �
Subdivision Name:
Drilling Contracwr.
Lot #
Distance {rom N Line��� _ Distance from Source of .
Pollution �`'
Tatal Depth: F� Yeld: ��GPM Static Water L,evel �_FG
Water Bearing Zones: Depth �„Z— F� 1�_ Ft. �'Ft Ft.
Casing: Depth: From , I� —_ to - FG Diameter. s Inches
TYPE: Steel G�a anized SteeL�---
If Steel, does owner approve: Yes No
WeighG �_ Thiclrness: ��Heigi : A�ve Ground: .� Inches
Drive Shce: Yes =--- No ; ,
Were Problems Encountered in Setting the Casing? Yes No �" `
If "yes" give reason:
Grou� Type: Neat Sand/Cement `� Concrete
Annular Space Width �"� Inches
Water in Annular Space: Yes No e--'"""
Method Pumped Pressnre Poiaed �--'
Depth From _�. to Fc
Materi Used: No. Bags Portland Cement _� Weight of 1 bag
lbs.
If mix e(sand gtavel, cuttings) - Ratio: ;�,_. to i
ID Plates: Yes v No
4 z 4 slab Yes � No
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I HEREBY CERT'IFY THAT THE ABOVE INFORMATION IS CORRECf AND THAT �
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTTH REGULATIONS SET r;
FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. �
.���.�. �..�',i/r' �r,��-�z
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„�e�t�e� locatl�n on reverse side.
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Date lssued
Sanitarian's Signature Date Completed
�
Person County Health Department
��w�age System Improvements Permit
Date: - '�1 This e' Void Af �5 Years Permit #-��
Owner: SR# �
L.acation/Directions: .���
Subdivision Name: � 1 f l. I.ot #
Lot Size: �, r15 c, �_t�r� s Type of elling:
Water Supply: Private: —� Public: Community:
Bedrooms: 3 Garbage Disposal
Basement Basement Fixwres
INFORMA� (�R'j'IFI�D BY
.,/ �. _.0 '
Canifaria a[%.� ��M1.✓ � OWIICi� fil V8�
REPAIR:`'� REEVALUATION: �� ``�.
- . _ �_-��-_-
Size of Septic Tank: � gallons Size of Pump Tank:
Nitrification Line: Ob �}( 3 '
Depth of Stone: 12 inches
Max Depth of Trenches:
Alternative System: Conv. Pump "- - LPP Pump
Remarks:
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Date Well Approved: Well should be 100 f� from any sewer system
BY Sanitarian
Date Sewage �Syste Approved: �" Z�% � 9�
BY �aN-:.•1� ���.•� sanitarian �p '� ;
CERTIFI
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CATE OF COMPLETION ,.,3
Contractor. T:r,r►v L w,s �
------------------------- �
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 hazazd. Septic tank and
nitrification line must be inspected and approved by a member of the Person County
Health Departrnent before any portion of the installation is covered and put into use. If .
the site plans or intended use change this penrut is subject to revocation.
(G.S.130 A-335F) nt 1
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Location of sewage disposal sewage system sketched on back. p
a
(OVER) '
6-12-�r1
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APPLICATION FOR: Date Receiveri:
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' . ( ) Improvement Permit ( ) Subdivision ( ) Other �
^ --- �_� �
1. Permit requested by: �,,,� j� �) � �.�%S�'lo�I Home Phone
Address:
T���cT Business Phone
2. Name and address of current owner: �.1 �, �.1,,,,�r
3. Property Description: Lot size Dimensions:
Front Left Right Rear
4. Tax map No. Township: Block No. Lot No.
H
5. Directions to property: State Road No. & Road Names, etc. �
�
N
.7
W
6. Permit requested for: New Installation Repaired
Additional Renovation re-using present system
7. Number of occupants of people served_
8. Dimensions of Proposed Structure: Width Depth
•�
•3
9. What tyge (if any) additions, expansions, or�replacement is aniicipated x
te the structure or facility that this sewage disposal sys�em is intended a
to sexve? '�
�
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D
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0
� �,10. Type of water supply: Well yes no: If no, name source of water �
supply: . Are there any wells on adjoining t., �
property? If so, identify location. o
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11. Type of structure or facility: 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 � ,
0
0
12. Clearly stake all corners of the property snd the corners�of all proposed �'
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 b
placed on the property. I understand that if any changes are made without ry
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. rn
_
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SIGNED
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FACTORS - SITE EVALUATION AREA 1 AREA 2 AREA 3 ARF.A 4
g S S S -
1. SLOPE (%) PS PS PS PS
U U U iJ
2. SOIL TEXTURE (12-36 in.) S S S S
(Sandy, loamy, clayey, PS PS PS PS
Note 2:1 clay) U U U U
3. SOIL STRUCTURE (12-36 in.) S S S S
(Clayey soils) pg ps PS
PS
U U U U
S g g S
4. SOIL DEPTfi (in.) PS PS PS PS
U U U U
5. RESTRICTIVE HORIZONS (in.) S S S S
(Impervious Strata, rock) PS PS PS PS
U U U U
6. SOIL DRAINAGE/GROUNDWATER S g g S
(�cternal � Internal) PS PS PS PS
U U U' U
7. SOIL PERMEABILITY S S S S
(Percolation Rate) PS PS pg
PS
U U U U
S g g S �
8. OTHER (specify) PS PS PS PS
. U U U �
9. SITE CLASSIFICATION --
(See below) '
SOIL SERIES --
S- Suitable __ PS - Provisionally Suitable U- Unsuitable
RECOI�II�IENDAT IONS / COMMENTS .
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies,
wet areas, fill.areas, we11s, water bodies, slope patterns, etc.)