A40 199. �
�Site Evalvution Application Date:
Fee Collected YES / 2d0 ` ���s�� ���
� p 0 ' �h 3
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v�)- �. �� PPLICATION FOR IMPROVEMENTS P�tHIT
1. Permit request�d by: ownerl;�ruspective owner:
p � � agent:
Address: � 'l �
Home Phone 4� :�'�\ _'1 5�3
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2. Name and address of current owner:
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Business Phone ��: ��
I O — �� —`� �i
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3. Property Description: Lot size: `�,• '�� `'`� ' /`-G,�
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la���•
`� ' � �
4. Tax map ��: (�-1a ,�1,�1 Township: ��c�-�C-�-�•�`� . �
Subdivision Name: ���- � �—�-�-�Lot ��:
5. Directions to proper
N e-- � �'�
d ��_& Roa es, etc.
6. Permit requested for: New Installation: Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served: �
8. Dimensions of Proposed Structure: Widtit: ��s- 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. 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:
Type of dwelling: House: _
Type of business:
Number of bedrooms: '
Basement? Yes No
Proposed: Exist' g:
Mobile Home: Business:
Number of Employees: .
Garbage Disposal? 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 is e. Permission 's hereby granted to
enter the property for the evaluation. G. - 3 F)
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Signed Owner or Authori ent
s
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Permit Issued
Permit Denied
Plat Observed
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i�ACTORS - SITE EVALUATION AREA 1 AREA 2 AREA 3 AREA 4
S S S S
` 1. SLOPE (X) PS PS PS PS
U U U :,T
2. SGli. TEXTURE <i2-36 in. ) S S S S
�Sandy, loamy, clayey, PS PS PS PS
Note 2:1 clay) U U U U
3. SOZL STRUCTUi2E (12-36 in. ). S S S S
(Clayey soils) PS PS PS PS
4 . SOIL DEPTH (i.n. )
.5. RESTRICTIVE HORIZONS (in.)
(Impervious Strata. rock)
6. SOIL DRAIt1AGE/GROUNDWATER
(�cternal & Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
U
S
PS
U
S
PS
u
s
PS
U
s
CS
U
S
U
S
PS
U
S
PS
u
s
PS
u
s
PS
U
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U
S
PS
U
S
PS
u
s
PS
u
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PS
U
S
U
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PS
U
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PS
U
S
PS �
U
S
PS
U
S
g. OTHER (specify) PS PS PS PS �
U U U U
9. SITE CLASSIFICATION
(See below)
SOIL SERIES
S- Sui.table PS - Provisional.ly Suitable U- Unsuitable
R FCOt�t1DAT ZONS / COMMF�ITS :
S.�:TE CLASSIFICATION JIAGRAH (Include: Soil areas, property lines. roads, streams, gullies,
Wet areas, fill areas. �rells, water bodies, slope patterns, etc.)
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Jun-23-�5 02r16P PERSON COUNTY HEALTH
: S��r�Y�ces
_ Impravements Permit (Establishcd/Rec�rded Lot)
_ lmprov�ments Permit (Unr�cc7rded Lot)
.._ Irnprovements Per�i�it (Mobi(e Home Re�lacc)
Improve►ncnts Permit (Addition)
� Bactcria
O ` • ' P . 02
1�+���c. �- �f� 7 � G
r�-r 2- � ��1-T�►v�
tequp`st�: .,
_ Reinspcction Uf �xisting System (Loan Closin�)
.._ Repair/Replace existin� Segtic System
JLPermit for New �Ve.11
_ Replace Existing Well
Wat�r S�inple to bc C
_ Chcmical _ Petroleum
l. F'erir�it rec�ue�ted by:
�wner/prasp .ctive o/wnterlagcnt:���'
4ddress: �r� a �i�7�, � �j aj
GG-�� i�� 5 P�c n57� , �
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� otrte Phone #: Z
a usiness Phonc #:
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Name and add�ess of currcnt owner.
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`� � � t I�SS G�a �5 2p .
t LL G'-bf � j'�y �-C .�-� a�
. Praperty pescription: Lc�t size: 2�� �-�
. Tax Map#: ��-f� o
Parcei#: l � q
Township: _ "%�A--i 2-�
. Directiotis tc� prc�Perty: Statc Road # c4� Road
f ames, etc.
l s � �-�—�. � ��T�cv�v pa<
v) •:— �_.�-.!7 r �. — - - -
` Pesticide
_ Lear]
7. Dimensi�ns or Proposed Structure:
Width: � �
Uepth: 2`�
,� �.�`..�
8. What type (if any, additions, expan�ions, or
replacement is anticipated to the sttltcture or facility
that this sewagc disposal systetn is intended to serve'?
9. Water s�pply t}�pc:
�rivate L� pt.tblic � community ❑ ti�ring ❑
Are any wells on adj�ining property'?Yes O No C]
If sa, identify location: !—o �" 1�
l,...� T �-3 _
10_ Type of stnicturelFacility: PropoSed: L�xititing: ❑
Type af dwelling:
Hvuse: �'Mobil� H�me: ❑ Business: []
Type of b��siness: T��
rlutnber �,f Ernployees:�i —,
Nutnber c�f bedcootns: �:,
Garhage Disposal? Yes ❑ Na C�}'
�' Basement? �'eti ❑ No C�l"If sv, # of b�sement fixtures:
�
�. Nutnber of occupants or peoplc to be served: ��
� ,�.__._
CLEAKLY S'�'AKE ALL CORN�ItS QF T�iE PYit)PF,RTY AND TH� COIZNFRS O� ALL
PROPQ5Cll 4TRUC1'URES.
T hereby rnake. application l� the �'erspn Coqitty Health bepax�tliellt for a site evaluatiim for tl�e on-sitc
sewage disposai system for thc above describcd prc�Perty. I agree that the contents of this aPPlicatian ace true
and represent the maximum t�aciliticti tc� he placed on the �roperty, I undcrstand if the site is alter�d or the
intended use changes, Ihe pern�it sh�ll become inv�tlicl. � Ut1dCCSl�nd tFtAt bCfC�re dTl I1t1pPC►veRlCtltS PerTtllt C3i1 he
irsued, I tnus� present a survey plat of the pmperty to the Health Uept. I t�ndcrstand th�t in the event I have nc�t
delivere�l � survey pl�tt of the property to the Hcalth UePt. within 60 X)AYS ufter the d�ite �f thc� ev�luation of
ttte site by tt�� Health Dcpt., this applicatian shall bccorne void and �11 fees paid fc�rfeitcd.
s
cd Uwner or Authc�r•ized Agent
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. A 0439
� PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIl'ROVEMENT PERNIIT
Tax Niap #��p Parcel # j� q'
Zoning ' Township ��r�'',4�u-�
Owner/Contractor �',Q,�,f 1'�i2,�S'f Date -.� 6— S
Location/Address o�,,, .�-� �: � �
S.R.#
Subdivision Name F.��' �N%u-e-.- � ' Lot# � �
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area •, a� Size of Tank �8��
SFD �' Mobile Home 1/ Size of Pump Tank
Business # of Bedrooms�_ Nitrification Line �oo �x,3 �
Max Depth Trenches
Pernut Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or intended use changed.
Well and Septic Layout by G!i �� ,��
Comments:
�17-99 Installed by� - �.i Approved by
8,�,/� WELL SYSTEM SPECIFICATIONS
Individual !/ Semi-Public Required Slab �/
Public Replacement Air Vent �/
Site Approved ✓ Required W� Lo� t/ ��D µ S- � 8�9
Well Head Approved �/ Well Tag
Grouting Approved �/ T�1 k S-�� �9 1 �, (o'� 6
Comments:
Date �-a (-q g Installed by o,' �xr.c�e�, _Approved by
7tus report is based in part on Wormation provided lhe homeowner or his/her representative in the application ubmitted for this pemut The
environmental health specialist is not responsible for false or misleading infortnation contained in the apptication. The environme�rtal health specialist
is also not responsible for concealed conditions on the propeRy or for statements in this repoit that may have resulted from false or misleading
statements provided to him in the apptication. Neither Person 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�permit.sam Ol/95 rev.1.0
ORIGINAL
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. � � PERSOH COUNTY ENVIROiZMENTAL HEALTH e ' • ; �` r �
. . . - . /�,,`, , . . �:
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� ' ' • • � WELL LOG - • . �'
, . . . �r; � c,.� `�� ..
Date: • �c�v� c� w,e.� .t� e.b s��� 1. .
Owner. � � ' � __ - - ____ .
- SR# ' � � .
Location/Directions: N��� �- �-�� -L� �� �T,� � 1�-, T� ,-. .— . •
^ - -r. _. .. . - -- - . _._. _ . � ,. _ r� .
,
Subdivision Name: _� � -� Lot #��
Drilling Con�ractor: _ �ca e c�e /(' I t�((,�.q. /�e� y �
Distance from Nearest Properry Line (Z� Distance from Source of
Pollution_ . (C� `
Total Dep.th:�_ Ft. Yield: Z_O GPM Static Water Level Z� Ft.
Water Bearing Zones: D�ep ` t.ilo ��[. � F� Ft.
Casing: Depth: From�_to�Ft. Diameter: Inches
TYPE: Steel - GalvaniZed Steel �
IF Steel, does owner approve: Y�s No
� Weight: � Thickness: /�r Height�Above Ground: 6�� Inches
Drive Shoe: Yes ✓ No = :
Were Problems Encountered in Setting the Casing? Yes No � �
Zf "yes" gir•e r�ason:
Grout: Type: Neat SandJCement ,/ Concrete •
Annular. Space Width Inches
Water in Aruiular Space: Yes No
_ .. Method: Pumped . . . . . �Pr�ssure � � Poured�_ � • • •, - . . .
Depth: From O to �. � Ft. . . - .
Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs.
If mixtuie (sand, gravel; cuttings) - Ratio: to
�ID Plates: Yes � No � � � •� � .
�� 4 x 4 slab Yes�—No
I HEREBY CERTIFY THAT THE ABOVE INFORM�ITION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH �y�THE PERSO�t C�Ui�iTY HEALTH DEPARTMENT. �
� --
�S gnaturc of Contractor atc
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