A40 197Site Evaluation Application
Date : io - a - 9�
Fee Collected YES � NO
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jG -�-��������`� APPLICATION FOR IMPROVEMENTS PERMIT _
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1.
Permit requested by: �prospective owner:
agent:
Address • � 9 i q � S� � �a....�--
Home Phone �k:
, Business Phone ��: �/_.�- �h l o
2. Name and address of current owner:
3. Property Description: Lot size: '`� �, pS c�.e..
4. Tax map ��: Township: \�-.�••-�
Subdivision Name: �.�r LQ...,"�",.ror- Lot 4�:
5. Directions to property: State Road �� & Road Names, etc.
6. Permit requested for: New Installation: ✓ Repair:
, Additional Renovation re-using present system:
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7. Number of occupants or people to be served:
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8. Dimensions of Proposed Structure: Width: Depth: _
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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.
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Water supply private? '� public? community? spring? .,�
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Other source? (Specify):
Are there any wells on adjoining property? � If so, identify location: �
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Type of structure or facility: Proposed: �ng�
Type of dwelling: House: Mobile Home: Business: _
Type of business: Number of Employees:
Number of bedrooms• Garbage Disposal? Yes ro
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. Permission is hereby granted to
enter the property for the evaluation. G.S. OA-335(F)
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Signed Owner or Aut i d Agent
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Permit Issued j/
Permit Denied
Plat Observed ��
rACTORS - SITE EVALUATION AREA 1 AREA 2 AREA 3 AREA 4
1. SLOPE (�)
2. SGIL TExTURE (i2-36 in.)
(Sandy, Ioamy, clayey,
Note 2:1 clay)
3 SOIL STRUCTLTiiE (12-36 in.
(Clayey soils)
4. SOIL DEPTH (in.)
5• RESTRICTIVE HORIZONS (in.
. (Impervious Strata, rock)
6. SOIL DRAIIZAGE/GROUNDWATER
{F�cternal & Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
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9. SITE CLASSIFICATION
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
RECOtR�NDATIONS /COTRIIIITS:
S�:TE CLASSIFZCATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gul.lies,
aet areas, fill,areas, wells, water bodies, slope patterns, etc.)
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Person County Health Department
Well Permit
Locadon/Direcaons:
Subdivision Name:,
Drilling Contractor.
SR#
#
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WELL CONSTRUCi70N
I7istance from Nearest Property Line Distance frorn Source oi
Pollution
Total Depth: �t Yeld: �,Z GPM Stadc Water LeveI �t,
Water Bearing Zones: Dep Ft F� F4
Casing: Depth: From �� Ft Diameter� Inches
T'YPE: Steel Galvar�zed Steel
�. If Steel, does owner approve• � No
Weigh4 Thic]rness: � Height Above Ground: Inc}fes ;
� Drive Shoe: Yes No
� Wae Problems F,ncountered in Setting the Casing? Yes .. No
' S If "yes" give reason• ' �
GmuG 'I'ype: Neat � San enty Concrete
Annular Space Width Inches
: Water in Annular Space: Yes No �
; Method: Pumved P�,�� �
; �� F� � � �.�—F -
; Matezials Used: No. Bags Portland Cement Weight of 1 ba�g ,�
- Ibs.
j If mizaue (satxl. grav�l, cuaings) - Ratio: co �
i ID Plates: Yes ✓ No
1 4 x 4 slab Yes T— No ,Z
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I HEREBY CERTffY THAT THE ABOVE INFORMATION IS CORRECT AND THAT �
TEIIS WELL WAS CONSTRUCTED CO ANCE WITH REG TIONS SE1" R
FORTH BY THE PERSON COUNTY PAR , �
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Sketch well locadan on reverse side.
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'taria;�'s Signawre Date Issued ,,,
Sanitarians Signature Date Completed
Person County Health Department
Sewage System lmprovements Permit
Date:�This Permit Voi After 5 Years Pe�ni[ #
Owner: _�ua�b l�' � Do�o �,i Sc�,Q�',�'ne �h SR# .����
Locadon/Directions: So r��
Subdivision Name: � a • Lot # _�c�
Lot Size: Type of Dwelling:
Water Supply: Private: Public: Community:
Bedrooms: �_ Gazbage Disposal
Basement Basement F' es
INFORMATION CERTIFIED BY
Environmental Health Specialist: er o nra '
REPAIIt: REEV A
Size of Sepdc Tank: ���� allons Size o�Pump Tank:
Nitrification Line: �/?/�7 / �l "z
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks: �
� � � � � � � � � � � � � � � � � � � �� � � � � �
Date Well Approved:
BY "
Date g te Approv • _
BY
Well should be 100 ft &om any sewer system �
Environmental Health Specialist
Environmental Health Specialist
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Contractor. � .
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— — — — — — — — — — — — — — — — — — — — — — — — — ��
Sewage System locarion, installation, and protection must meet state and locai �
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 hazard. Sepdc tanlc and �
nitrification line must be inspected and approved by a member of. the Person County Z
Health Departrnent before any portion of the installadon is covered and put into use. If �
the site plans or intended use change�this pernut is subject to revocation.
(G.S.130 A-335F7 = —
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I.ocation of sewage disposal sewage system sketched on back.
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(OVER) —
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