A40 194i. .
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Site Evaluation Application Date•
Fee Collected YES `� NO
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1,p e.�e1 �� G� APPLp TT_ON FOR IHPROVEMENTS PEEtMIT
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1. Permit requested by: owner/�ruspective owner:
_ agent:
Address: ,U.(l. ,Y��
Home Phone �� : _s�i7_
2. Name and address of current owner:
Business Phone ��:
3. Property Description: Lot size: � g��
4. Tax map ��: %��6=��� Township:
Subdivision Name: Lot ��
5. 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: o�
1�
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?
10. Water supply private? �/ public? community? spring?
Other source? (Specify):
Are there any wells on adjoining property? If so, identify location:
11,
Type of structure or facility: Proposed: Ex sting:
Type of dwelling: House: Mobile Home: � Business: _
Type of business: Number of Employees:
Number of bedrooms: �arbage Disposal? Yes No
Basement? Yes Iro 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 A thori c: Agent
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Permit Issued 4�• �"
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Permit Denied
Plat Observed
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i�ACTORS - SITE EVALUATION AREA 1 AREA 2 ARF.A 3 AREA 4
S S S S
1. SLOPE (X) PS G�p°jo PS Llp°Jo PS � IO�Zo PS
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2. SGII. TEXTURE <i2-36 in. ) S r
(Sandy, Ioamy, clayey, PS � P � � � PS
Note 2:1 clay) U � U � U � U _
� SOIL STRUCTURB (12-36 in.) S S S S
v (Clayey soils) � � PS PS
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4 . SOIL DEPTH (i.n. )
5. RESTRICTIVE HORIZONS (in.
(Zmpervious Strata, rock)
6. SOZL DRAIIdAGE/GROUNDWATER
(�cternal & Internal)
7. SOIL PERMEABILITY.
(Percolation Rate)
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9. SITE CLASSIFLCATZ�JN (� D
(See below) i S T S PS
SOIL SERIES
S- Sui.table PS - Provisionally Suitable U- Unsuitable
R ECOt-QSErIDAT IONS / COi R IEriTS :
S:�TE CLASSIFICATION �IAGitAM (Include: Soil areas, property lines. roads, streams, gulZies,
Wet areas, fill areas, vells. watex bodies, slope patterns, etc.)
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT PERNIIT
Tax Map # A'�{-0 Parcel # J9�/
Zoning Township FjQi P� �Ve,v
Owner/Contractor Gloria wmnhY� Date �- lb - 9S
Location/Address �' M; oa-t �iwv 4 �s� S-Fo Flat K;YQ,, Plarrta-�an n� riah+, t.�+- I6
on �icple Dv S.R.#
SubdivisionName �a�_ Ri�s,►- ��antalion Lot# /(o
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SEWAGE SYSTEM S�ECIFICATIONS
Repair Lot Area /• a0 Acra Size of Tank /tYJo
SFD � Mobile Home �( Size of Pump Tank I�A
Business # of Bedrooms 3 Nitrification Line �{�e' X 3°
Max Depth Trenches /g�' - Z�j'�
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site i altered or intended use changed:
Well and Septic Layout by ' ".s. �
Comments: �o� sQn�ic lo` 'f'a �►vnent�.a iY� ,_ a� �nn i�o��, IQ'� -�um w�. �
Date t�.. - 5 `3.S Installed by �;,,.w,,,,,,L ��w-y. Approved by �.v ..c;2..� t3 .�.,,.�.�
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WELL SYSTEM SPECIFICATIONS
Individual� Semi-Public
Public Replacement
Site Approved X
Well Head Approved � -
Grouting Approved �- i 3- 9S� r.�. D�)
Required Slab �}- -/3-�.��w• ���
Air Vent
Required Well Lo� ��, _ 9 s� w t d,
Well Tag �f--�,3-iSC�� �`
Comments: j�� �Q �'fy� p��tv �in�n (0�` "{`vrrn� aP��ir �n� �esS `i�i en (�D ��
Date �i - I3 -y� Installed by �r��.. u�.�2¢ �, Approved by�(./ �-..c.�,�-.
This report is based in part on infonnation provided the homeowner or his/her representative in the application submitted for this permit Tlie
environmental health specialist is not responsible for false or misleading infotmation contained in ihe 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 Pecson County nor the environmental health specialist wazrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro\permitsam O1/95 rev.1.0
ORIGINAL
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Date:� -l3 -�..�'
Owner: G�o ►-. �-
Location/Directions:
PrRSON COUN'TY �NV]:RONML'NTAL IU;ALTII
WLI,L LbG
SR#
.niui;:�_VISIOII N�1171C: �/�' �" yt r �,�1}-n�,�• o.� .L.OI �� f L.
Drilling Corl�actor: �:s�.� li1Q �/ �,-; 11:� �_,rJ��
WEt,L CONSTRU� �
Distance froin Ncarest Pro�x:rty Liiic ___/.5 �h.�.s llist�uic:u l�rom Source of
Pollution � Go �/r� s
Total Dep.th:_ /o �-- Ft. Yicld: �3 � GPM Static VYater Level Ft.
Water Beari��g Zones: Depth �Ft. Ft. Ft. Ft.
Casing: Depth: From �to�Ft. Diamet�r:_c�%,�_Inches ,
TYPE: Stcel Galvanizeci Stee]_�
If Stecl, does owncr approve: Xcs ..No_
� Weight: /,� Thxckness: 1 R'� ,Heiglit Abvve Ground: �� Inches
Drive Shoe: Yes No - i
Werc Problems Encountcrccl in Setting the Casing? Ycs No .� �
.►i "yc:s'' givc; rcason:
Grout: Type: Ncat S:u�d/Cement � Coricrete � '
Annular Space Width 3 Inchcs
Water in Annular Spacc: Yes No �—`
Mcthod: Ptunpcd Prc:ssure Paured� ✓
Dept��: Fr�rr� (�_ to_�o rt.
Materials Uscd: No. Bass Portland Cemcnt�_ Weight of .1 bag 9� lbs.
If mixture (sand, gravcl, ctittinbs) - IZatio: Z to �
ID Plates: Yes ✓ No � �_ �
4 x 4 slab Yes�� No
I HEREBY CERTIFY THAT'I'HE ABOVE INFORM�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH REGULATIONS �SET
FORTH BY�THE PERSON COUN�('Y IIEAI,TH DEPARTMENT.
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Sibnaturc �I� (_.'c>ntrlc:tor Datc
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