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=€�erson County Health Department �
Sewage System Improvements Permit
�
Date:�'" 17� / This Permit Void After 5 Years Pemiit #
Owner: r' / c� y,'� f-I � �►7T1� r��� "�, .�1�� 1
Location/Directions: a o � �
Subdivision Name: � � �� � �' Lot #�' �
Lot Size: �}����f�3 YPe of Dwelling:
Water Snpply: Private: —� Public: Community: 1
Bedcnoms: �_ Garbage Disposal � �
Basement Basement Fixtures
INFORMA D BY
$��j�: o er or represa�tative
REPAIIt: VAL ATION:
Size of Septic Tank: �US��3 mp Tank:
Nitrification Line: _
Depth of Stone: 12 inches
Max Depth of Trenches:
Alternative System: Conv. Pump LPP Pump .
Remarks: --
-------------------------
Date Well Apptoved: Well should be 100 ft from any sewer system
BY Sanitarian
Date Sewage Sys�em Approved: ��/-�-9/
BY_�r,/ �lo•w.- Sanitarian
CERTIFTCATE OF COMPLETTON
�
Contracwr. �
------------------------- �
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Sewage System location, installation, and protection must meet state and local �
regulations. Septic tanlc 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 hazard. Septic tank and
nitrificarion 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 permit is subject to revocation.
(G.S. 130 A-335F) 1
1
Location of sewage disposal sewage system sketched on back. `�
�
(OVER)
�'
��erson County Health Department �
Well Permit �
This
Locadon/Directions:
Subdivision Name: _
Drilling Contractor.
Void Afte 3 Years '�
�'�` ° 5����/�J�
r
�r'� Lot # f 7
r-�,s 1,� 1 � lf �
�ELL CONSTRUCI'ION ►b
Distance from Nearest Pro�ty Line�.J Distance from Source of �'
Pollution d u- co,
Total Dep :� F� Yield: ��GPM Stadc Water Level �FG �
Water Bearing Zones: Depth '�(� F4 i�� Ft /� FG F�
� Casing: Deptti: From �_ w�� FG Diameter: � Inches
TYPE: Steel Galvazuzed Steel `-�
If Steei, does owner app;ove: es No
� • WeighC �3 Thiclrness: Height Above Groimd: _��nches
Drive Shce: Yes No
Were Problexns Encoimtered in Settin the Casing� Yes No �'�
g
If "yes" give .
Grou� Type: Neat �`� Sand/Cement Concrete
Annular Space Width 3 Inches
Water in Armular Space: Yes No •�
Method: Pumped Pressure Poured ��
Depth: From �— to FG
Materials Used: No. Bags Portland Cement � Weight of 1 bag
` � _ lbs. �
If mixture (sand, gravel, cuttings) - Ratio: ' �- to i
ID Plates: Yes � No
4 x 4 slab Yes No
�.S' 1�-S' G �- p- n;' �•�— '
I HEREB CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE W1TH REGULATIONS SET
FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT.
Signature of Contractar Date "
- p ,_�,o_
'an ignature Date Issued
�a�..� �o-=.� �v � /2-9/
Sanitarians Sign re Date Completed
Sketch well location on reverse side.
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)
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( ) Improvement Permit
1. Permit re uested by:
Address : � � �hX �Qi
APPLICATION FOR:
(V) Subdivision
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2. Name and address of current owner:
Date Received:
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( ) Other �
Home Phone � �
Business Phone j?y�.�
3. Property Description: Lot size ��1� (�,Cpn�) Dimensions:
Front Left Right Rear
4. Tax map No. Township: �� e_ Block No. Lot No.
5. Direction�s to property: �State Road No. & Road Nam�s, �trC.� n' �
1 . , - s�J C� � I
6. Psrmit 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 !
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9. What type (if any) additions, expansions, or�replacement is an�icipated x
te the structure or facility that this sewage disposal sys�em is intended a
to serve? '�
��
,10. Type of water supply: Well yes no: If no, name source of water
supply; Are there any wells on adjoining t.,
property?yvp If so, identify location. rt
�
il. Type of structure or facility: Proposed Existing
Type of dwelling: House Mobile Hom� Business
Type of business Number of Employees
Number of Bedrboms ,� 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 x'
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 .d
placed on the property. I understand that if any changes are made without n
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 60 months from dat �
of issue.
�1,���.�.�� �1���
SI
r�ecTORs - SITE E�IALUATION
1. SLOPE (%)
2. SOIL TEXTURE (12-36 in )
(Sandy, loamy, clayey
Note 2:1 clay)
3. SOIL STRUCTURE (12-36 in.
(Clayey soils) �
4. SOIL DEPTfi (in.)
5. RESTRICTIVE HORIZONS (in.)
(Impervious Strata, rock)
6. SOIL DRAINAGE/GROUNDWATER
(External � Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
AREA
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AREA 2
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AREA 3
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AREA 4 ;
8. OTHER (specify) PS PS PS PS
. U u U �
9. SITE CLASSIFICATION
(See below) �
SOIL SERIES
S- Suitable PS - Provisionall Suitable U- Unsuitable
RECOMMENDATIONS/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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