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A40 180��rson County Health Department Sewage System Improvements Permit Date: 30 _`� ,I,t owner: _,� Location/Directions: Permit Void Afte 5 Years Permit # � 2�.1 / � o n�. sx# � s. � Subdivision Name: ���-� l� ��-y" � �'�^vrt�-�-a-^ Lot # fi Lot Size: 1� ��� Type of Dwelling: � Water Supply: Private: �� Public: �� � Community: � Bedrooms: � Garbage Disposal � Basement Basement �F' @ INFORMA OFI D Y `-� � ' 5���: � �^;�,%I '� :��--' owner tesentative REPAIR: � REEVALUATION: ------------------------- Size of Septic Tank: �'""-" gallons Size of Pump Tank: Niuification Line: � �c 3l Depth of Stone: 12 inches Max Depth of Trenches: Altemative System: Conv. Pump - LPP Pump Remarks: ------------------------- Date Well Approved: � - S `� / BY (� Date ag S s m A rov :— Well should be 100 f� from any sewer system Sanitarian �, ll't . .. . : .' . I u�''''�'' i • • i• • I � � . ,. , L „ , �, i i-. Sewage System location. installadon, and protection must meet state and local regulations. Septic tank 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 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 pem►it is subject to revocation. (G.S. 130 A-335F) Location of sewage disposal sewage �stert}sketched o� back. f f! ;�-r /u.� � ✓��---- COVER) � � b T. Person County Health Department � Well Permit � Date: �'12-� �Th' Permit Void After 3 Years '� Owner � SR# 1 �75��'�+ Subdivision Name: t # Drilling Contractor. WELL CONSTRUCITON ►b Distance from Nearest Praperty Line Distance from Source of �' Pollution �, Total Depth: G Yield: �GPM Static Water Level FG � Water Bearing Zones: Deg� �1.,,�_Ft FG�F� Casing: Depth: From f� w�j� Ft Dian�r. Inches TYPE: Steel � Galvanized Steel ff Steel, does owner approve: No Weigh4 Thiclmess: Height Above Ground: Inches Drive Shce: Yes No Were Problems Encountered in Setting the Casing? Yes No If "yes" give reason• "b Grou� Type: Neat S ement Concrete � Annulaz Space Width Inches Water in Annular Space: Yes No ,/ Method: Pumped�.q� Pr s e Poured Depth: From V co �_ FG Materials Used: No. Bags Portland Cement Weight of 1 bag lbs. If mixture (sand, �vel, cuttings) - Ratio: to _ ID Piates: Yes No ►b 4 z 4 slab Yes � No � �. De th .� I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH R GULATIONS SET FORTH BY THE PERSON COUNTY H�\��'I-� P NT. � I� I�' I ll� Sketch well location on reverse side. Date Sanitarians Signature Date Completed �'� �*IOT'E: 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. y (1) (z) � e � � Person County Health Department Existing Sewage System Report Eor: " Mobile Home �placement . Addition Requestee: �OZG���e Lv�✓Q Home Phone# 3Cv7'���'3 �� � ��a,9�a,�,�i /�� _ ausiness# 9II ��y ���'� /`7U�d �G / /i ���J � �� `P ax M ap # �U %Sd Location/Directions: /��a� ��ver �/°�TQ' "o'`i 2°y � 3 r� �o� o� le�� - - Original Permit Located � Septic System Designed Eor: Kesidential � Business � Other (speci�y) # Bedrooms 3 # Employees Other Uate Tnstalled �' as'9f Water supply /r'�votc l�e�/ 'Pype ot 5ystem Lo�vY ,.�v% --Sv/�faca Nitritication Line ��v'�3' Tank Size %(l[� �c� ��o� — Certified Operator Required i"� On site wastewater disposal system showes no visually apparent malfunction on �x�st����/Ster , /veUe� �s'cd , �% 8�9ni Yermission is granted tos ���QcC .3 l�c�'�o�w /%v.h��/c �/or� v�v ����s �a� aN� vst Bxs;s����9 ..�.c�pf��c .Si/s�cr�. Rccording to the attached site plan.. - Comments: ��eCaMr►eNd /�i++,o�`•.�q �a�� EUGc �/ -s t/eerS. _ �o�plc�� �c%l�l/ ��ed -� 1/e,;�� �'Pc , /�losr ��'�, _ �;nvironmental Health S�-pr�►-. �� � v. .�.: . s �,; �. __�.._ - . .. DATE a w U � a z Amount paid L66'6� Receipt !� ' c� l l P�j • f: • 3 —34 -9 � Date _ Im�rovements Pecmit.(Established/Recorded Lot) �_ Reinspection of Existing System (Loan Closing) Improvements Permit (Unrecorded Lot) t lmprovements Permit (Mobile Home R� Improvements Permit (Addition) Repair/Re�lace existing Septic System Pecmit for New Well _ Replace Existing Well 1. Permit requested by: . 7. Dimensions or Proposed Structure: owner/prospective owner/agent: t72e� e�-QY� Width: 1� X 7� A dress: �� � 1 Depth: \ �- � 8. What type (if any, additions, expansions, or replacement is anticipated to the structure or facility that this se�vage disposal system is intended to serve? Home Phone #:�`-36�(- �'lf3 usiness Phone#:�'?t�-<aSy:al�b � 6 �3a-3 PM 2. Name and address of,cucrent owner: 9. Water s ply t}'pe: private public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No �� If so, identify location: 3. Property Description: Lot size: !� I��-C. . Tax Map,�: �,t�.� d I—�1' � 10. Type of structurelfacility: Proposed: ' Existing: Q Parcel#: _ ��C) F��� Type of dwelling: Township: FI a�.�- �. i Ve� �� � House: ❑ Mobile Home: Business: ❑ 5. Directions to propecty: State Road #& Road Type of business: ames,gtc. Number of Employees: �� 1� ��j �, �QM� pt� � Number of bedrooms: .�_ Garbage Disposal? Yes ❑ No �" Basement? Yes ❑ Nofl'If so, # of basement fixtures: 6. Number of occupants or people to be served: ` CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. , I heceby make application to the Pet'SOn COunty �3Calth Department for a site evaluation for the on-site sewage disposal system for the above desccibed property. I agree that ttie 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. I undecstand that before an Improvements Permit can be issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not delivered a survey plat of the property to the Health Dept. wi[hin 60 DAYS after the date oE ttie evaluation oE the site by the Health Dept., this application shall become void and all fees paid forfeited. Signca Ownec or i4iitt�orized Agent (�Improvement Permit APPLICATION FOR: ( ) Subdivision Date Received: ( ) Other l. Permit requested by: Home Phone�.3 0 Address: S 3 a o Business Phone .� / 2. Name and address of current owner: �• 3. Property Description: Lot size /,�(o Dimensions: Front Left Right Rear 4. Tax map No. � T� sh� �./�f 5. Directions to p�operty:�t.�ate Road No. & Block No. Lot No. Names, etc. � Nc � 6. P�rmit 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 tyge (if any) additions, expansions, or�repincement is an`icipated te the structure or facility that this sewage disposal sys�em is intended to se�-ve? ,10. Type of water supply: Well ►' yes no: If no, name source of water supply: Are there any wells on adjoining propertya If so, identify location. 11. Type of structure or facility: Proposed ���' Existing Type of dwelling: House Mobile Home� Business Type of business Number of Employees_ Number of Bedrboms� Number of automatic appliances Basement Number of basement fixtures 12. Clearly stake oll corners of the property snd the corners of all prop 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 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 bo months from dat of issue. SIGNED z w 3 m H 0 t � N "J' �+• 'C3 � H a x � a � � � � � � r 0 r+ � � � 0 � " x � FACTORS - SITE EVALUATION AREA 1 AREA 2 AREA 3 AREA 4 S S S S 1. SLOPE (%) PS PS PS PS ' U U. U U 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) � PS PS pS ps U U U U S S S S 4. SOIL DEPTIi (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 S S S (bcternal � Internal) PS PS pS pg U U U U 7. SOIL PERMF.ABILITY S S S S (Percolation Rate) pg ps p5 PS U U U U ' S S S S 8. OTHER (specify) PS PS PS PS . U v U u 9. SITE CLASSIFICATION -�- (See below) ' SOIL SERIES -- S- Suitable PS - Provisionally Suitable U- Unsuitabl.e RECO�NDATIONS/COMMENTS: `� SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill.areas, wells, water bodies, slope patterns, etc.)