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A40 192�` z Person County Health Department � Sewage System�lmproveme�`nts Permit Date: �� g This Permit oid After 5 Y� rPerm�t # r�-�39 � Owner: � / � � � s�� SR# - Location/Directions: N w• t 5 � P1P.;,,a-a �; .,. p�r. � Subdivision Name: F�� `O��' 0.`^��` ^ Lot #�_ Lot Size: �• �� Type of Dwelling: M� � c k�{o.��- . Water Supply: Private: Public: Community: Bedrooms: 3 Garbage Disposal � ' Basement - Basemen� Fixtures INFORMATION CERTTFIED BY ' ` ' Environmental Health Specialist: _ o or re�enta '� ` REpAIR; REEV UA ON: � p� ------------------------- � Size of Septic Tank:1000 gallons Size of Pump Tank: �lfl ¢ Nitrification Line: � Depth of Stone: 12 inches , , , o� Max Depth of Trenches: � `� � � ;,.. Altemative System: Conv. Pump LPP Pump Remarks: � i Z ► 2 - �1� -D n � -------------------------- � Date Vi/ell Approved•� Well should be 100 fG from any sewer system gy G� �.{� �i1yw,.,Environmental Health Specialist Date � age Systgm Appmv • �' � " By R Environmental Health Specialist � CER ATE 6F COMPLETION ,� Contractor. ��Liif� ��' , _, � _ _ _ _ _ _ _ _ _ _ _ _ _ _ _� _ — _ _ _ _ — _ _ � • 'C Sewage System location, installation, 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 ni!rification line must be inspected and approved by a member of the Person Connty Health Depaztment before any portion of the installation is covered and put into use. If + the site plans or intended use change this permit is subject to revocation. (G.S.130 A-335F) . I.ocation of sewage disposal sewage system sketched on back. (OVER) 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. l (1) ' (2) . ■■■■��■■�■■■ ■■■■�■��.■�■■ ��a��■u��■■�■ ■�� v��i��■� :��■ ■■a��ia��■�� ■��■ ��■�� i��:��t��s�� ■s��; ��■� ■�i�t�►��i��■ ■■��i�..� ��t��■ ��i��■�� i��.�rt�� i�� ■ �e�i��■ ��i��■i��■ ��►,�� i��.. ��■�■ ��i��■ ��i��n■■ ■��la111 ��i��■ ■i�\��/r��■■ : ► �ou�-� ld�c� �C�2 Person County Health Department Weli Permit Date:�/�s This Permit Void After 5 Years Owner. �"-��+—�sxss __ 3�s`�p�'��"y�"Y`O`� SR# _ ision Name: Drilling Contractor: v�n�.�.�.vi�a�nv�,iivi� -.. Distance from Nearest Properry Line Distance from Source of Pollution ' ' Total Dep�' FG Yield: �� GPM � Static Water Level `� F� Water Bearing Zones: Dept}��FG' --� FG �'t. Casing: Depth: From U to Ff. Diameter: Inches. I TYPE: Steel Galvanized Steel ✓ � If Steel, does ownet approve: �' �s�No • Weigh� Thickness:�� Height Above Ground:' � Inches Drive Shoe: Yes No Were Problems Encountered in Setting the Casing? Yes No If "yes" give reason: i Grout: Type: Neat $gnd/Cement Concrete Annular Space Width� �— Inches Water in Annular Space: Yes No Method: Pumped� Pr Poured �� Depth: From to F� Materials Used: No. Bags Portland Cement Weight of 1 bag_]bs. If mixture (sand gravel, cuttings) - Ratio: to ID Plates: Yes � No 4 x 4 slab YesJ/ No I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH EGULATIONS SET FORTH BY THE PERSON COUNTY H T EP ME ' 3 2�( 5 Signature of Contra or Date � � /�14s an 'an s' ature Date Issued LU/,� �,cti.�.,..� x ' 3 �-`�j" Sanitarian's Signature Date Completed Sketch well location on reverse side. b � � � 'd � z 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. (1) • „ . (2) . , � I i -I I � I�.,. �;� �� - -- -- �� - I - - Site Evaluation Application Fee Collected YES / Pd ►`��-v3q�'7 �e�� a5,4� e%# NO Date: �� - � - �� APPLICATION FOR INPROVEMENTS PIIiHIT 1. Permit requested by: owner/prospective owner: `�� --� . � . . agent : �h S Address: Home Phone ��: `1��1 � �o Busi��e�s Phone �i: �- - . r 2. Name and address of current owner: �..��,. , 3. Property Description: Lot size: �, 4� �.p _ � , `c�' � 4. Tax map ��: `{o- �g Township: Subdivision Name: Lot ��: 5. Directions to p p� State Road �� & Road Names, etc. '�..�- o.�- �� 6. Permit requested for: New Installation: ✓ Repair: Additional Renovation re-using present system: z 7. Number of occupants or people to be served: � �' 8. Dimensions of Proposed Structure: Width: �`` Depth: `�f� 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? 10. Water supply private?j�- public? _ Other source? (Specify): Are there any wells on adjoining property? community? spring? If so, identify location: 11, Type of structure or facility: Proposed: Exi.ting: Type of dwelling: House: Mobile Home: � Business: Type of business: Number of Employees: , Number of bedrooms: 3_a w- 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. Permiss"on is hereby granted to enter the property for the evaluation. G.S. OA-3 5 F) �� Signed Owner or Auth iz d Agent � m H w x � w ,; Permit Issued Permit Denied Plat Observed ��_� 1U /1'� 1�� I � �J-'� � 0 P�a�� t�:�� v� i?ACTORS - SITE EVALUATION AREA 1 AREA Z ARF.A 3 AREA 4 S S S S 1. SLOPE (�) PS� � S�b PS PS PS U �, • U U ;.1 2. SGIL TEXTURE (12-36 in.) S S S S r (Sandy , loamy, clayey, PS� C�`�yP�/ PS PS PS Note 2:1 clay) U U U U 3. SOZL STRUCTiJRE (12-36 in. ) S S S S (Clayey soils) PS �� f1 �' PS PS PS U U U U S ��r� S S S 4. SOIL DEPTH (in. ) � s�e�� pS PS PS i3 U U U .5. RESTRICTIVE HORIZONS (in.) Q S S S (Iuipervious Strata� rock) PS �U:.� PS PS PS u u u u 6. SOIL DRAI2�IAGE/GROUNDWATER Q �� y S S S (F.�cternal & Internal) PS ��.�1e 5 PS PS PS � U U U U 7. SOIL PERMEABILITY � � S S S (Percolation Rate) PS � u PS PS PS u ��3 u u U s � s s s $. OTHER (specify) PS '�� PS PS PS � U U U U . SITE CLASSZFICATION (See below) SOIL SERIES S - Suitable R F_COt�R�i1DAT IONS / COMMF.t�ITS : [rJ PS - Provisionallv Suitable U- Unsuitab S:�_TE CLASSIFICATZON �IAGRAH (Include: Soil areas, property lines, roads. streams, gullies. Wet areas. fill areas,�.rells, water bodies, slope patterns, etc.)