A40 201_ � ,
_ �erson County Heaith Department
Sewage System Improvements Permit
Date: �'I'his Permit Void ^After 5 Y Permit #�� 9�� -
�Wi10I: � . ./h � d �/-I�r �—� Y-�-��n $R# ��
LLlCSt10i1�DlICCtIOflS:
Subdivision Name• I P '/ 6� Lot #
I.ot Size: C� c�✓�SType of Dwelling:
Water Supply: Private: —� Public: Community:
Bedrooms: � Garbage Disposal
Basement Basement F' _
INFORMA� C�_.R�IF�D BY
/ wner or represeatauve
REppIR; — ' ' REEVALUATION:
-------------------------
Size of Septic Tank: � 'r gallons Size of Pump Tank: —
Nitrification Line: �� �3�
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump I-PP PumP
Remarks:
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Date Well Approved: Well should be 100 ft from any sewer system
BY Sanitarian
Date Se e Sys m Approved: 9—!�: 9 2
BY � � ; � i v � Sanitarian
�TINi ATE OF COMPLETION ..�
Contractor. ��da;C "'� �
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Sewage System location, installadon, and protection must meet state and lceal �
reguladons. Septic tank should be pumped out every 3 to 5 years anci shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and
nitrification line must be inspected and appcoved by a member of the Person Counry
Health Departrnent before any portion of the installation is covered az►d put into use. ff
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)
R�rson County Heaith Department
Weil Permit
Date:'" �' L This Permit Void After 3 Years
Owner: L Nl. -� �T�/�I a✓-fin SR# �s% _
Locaaon/Direcdons: �
Subdivision Name:
Drilling Contractor.
• �I : �lM��
h I.ot #
Distance m Nearest Property Line,�s �f'In:s Distance from Source of
Pollution �-S D
Tatal Depth: •G Yeld: �GPM S tic Water Level �FG
Watet Bearing Zones: Depth Ftio'��FG FG_,_Ft.
Casing: Depth: From �_ co I!' F� D iameter: 6� I nc hes
T'YPE: Steel Galv Steel ��
If Steel, d owner approve: Yes No
Wei t: � Thiclmess: Height Above Ground: Inches
8h
Drive Shce: Yes L----` No
Were Problems Encountered in Setting the Casing? Yes No L--- -
If "yes" give reason: -
Grou� Type: Neat Sand/Cement '� Concrete
Annular Space Width �_ Inches
Water in Armular Space: Yes No �----
Method: Pumped Pressuze Poured � /
Depth: Fram _1� to ► F�
'als Used: No. Bags Pordand C�� Weight of 1 bag
lbs.
If ' ture (sand, g�el, cuttings) - Ratio: _� co �_
ID Plates: Yes( ,� No
4 z 4 slab Yes i-'� No
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I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECf AND THAT �
THIS WELL WAS CONSTRUCTED IN ACCORDANCE W1TH REGULATIONS SET ,�
FORTH BY THE PERSON COUN'I'Y HEALTH DEPARTMENT. �
�i�� Ltl � ('.cL(�-�
Si of o ' Date
7 7�'�z
anitarian s Signature Date Issued
Sanitarian's Signatuze Date Co pleted
Sketch well location on reverse side.
Site Evaluation Applicatio Date: �� `_ ��
Fee Collected YES � NO
� �q3"� � � � � .� q a'
� ���' _ *� `� APPLICATION FOB IMPROVEMENTS PERHIT
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1. Permit requested by: owner/prospective owner:
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Address: ����j0�( ��33 � �bX golZ.Ut�IVC� �'i.
Home Phone ��: �f�j- C%`y/� � Business Phone ��:
2. Name and address of current owner: � D� �- {�-1 �'`�
5311 �oD5,�n1� C 1Z�SS IZI� _ �_��� o
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3. Property Description: Lot size: ,�, (�� 1� �.'
P�A7 Cpg rN �r �, 1�� �l(G� rZ- i�- �'��
4. Tax map ��: Township : � T = V L/�
Subdivis ion Name : FL./}�T 12 .z VE IZ L!-}� T,Q %�Otil Lot ��:
5. Directions to property: State Road �� Road Names, etc.
f n 4 I� � r� �1-i- ��.r � al iJ � � h x� a r� c� ,�li C___�_'�
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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: ��
L
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8. Dimensions�,of Proposed Structure: Width: �C��� T Depth: �{ T• "
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?
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10.
11,
Water supply private?
Other source? (Specify):
Are there any wells on adjoini
public? community? spring?
property?
If so, identify location:
Type of structure or facility: Proposed: Existing:
Type of dwelling: House: Mobile Home: _;� Business:
Type of business: Number of Employees:
Number of bedrooms: Garbage Disposal? Yes No X
Basement? Yes No �C _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 issu . Permission is hereby granted to `
enter the property for the evaluation. G.S. 13 - 35(F) �
. � � - �, ' . �
Signed 0 er or Authorizeci Agent
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Permit Issued _�_ f � ct� �
Permit Denied
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Plat Observed
rACTORS — SITE EVALUATION AREA 1 AREA 2 ARF.II 3 AR.EA 4
1. SLOPE (X)
2. SOZL TEXTURE (i2-36 in.)
(Sandy, loamy, clayey,
Note 2:1 clay)
3.. SOIL STRUCTLTRE (12-36 in.
(Clayey soi.ls)
4 . SOIL DEPTH (in. )
5. RESTRICTIVE HORIZONS (in.)
(Impervious Strata, rock)
6. SOIL DRAIIZAGE/GROUNDWATER
(bcternal � Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
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9• SITE CLASSZFICATION
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
RECO2��fEiIDATIONS / COt4iEDITS :
SL�TE CLASSIFICATZON DIAGRAM (Include: Soil areas, property lines. roads, streams, gullies,
aet areas, fill ,areas, vells, �aater bodies, slope patterns, etc.)
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