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Permit (Established/Recorded Lot) �_ Reinspection of Existing System (Loan Closing)
Improvements Pernut (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
Repair/Replace existing Septic System
Permit for New Well
_ Replace Existing Well
_ Bacteria � _ Chemical I _ Petroleum � Pesticide � _ Lead
1. Permit requested by: 7. Dimensions or Proposed Structure:
owner/ ros ective owner/agent:.��� Cc_� � Width:
ddress• ��� , �,� � ,� � /r Depth:
"�-- 8. What type (if any, additions, expansions, or
-� � replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
ome Phone #:
usiness Phone #:
2. Name and address of current owner: 9. Water supply type:
c private F� public ❑ community ❑, spring ❑
` p ' Are any wells on adjoining property?Yes ❑ No ❑
If so, identify location:
3. Property Description: Lot size: 1 A �re
. Tax Map#: ��� Lo� ►4 10. Type of structure/facility: Proposed: ❑Existing: ❑
Parcel#: /� 3 RocK�° Type of dwelling:
Township: �/� �.� L� �1` S House: C�'Mobile Home: ❑ Business: ❑
5. Directions to property: State Road #& Road Type of business:
ames, etc. Number of Employees:
�' � S- �� a ,� Number of bedrooms: _��.1�
,Y � Garbage Disposal? Yes ❑ No ❑
Basement? Yes ❑ No �If so, # of basement fixtures:
6. Number of occupants or people to be served:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CUx1v�x5 ur� ALL
PROPOSED STRUCTURES.
I hereby make application to the Person County Health Department for a site 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. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
z � Signed Owner or Authorized Agent
Permit Issued ��
Permit Denied ❑
Plat Observed �
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Signature Date
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I. SLOPE (%) S S S S
PS . � � PS PS PS
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2. SOQ.7'E7C7URE(12-36INJ S S S
(SANDY, LOAMY, CLAYEY, NOTE 2:I CLAI� PS /' _ 4 -iTI' PS PS PS
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3. SOII. S7RUCiURE (12-36 W.) S S S S
(CLAYEY SOILS) s� PS PS PS
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4. SOIL DEPTIi (IN.) S S S S
S T��j �� PS PS PS
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S. RESTRIC77VEHORIZONS(IN.) S S S S
(IMPERVIOUS S'IRATA, ROCK) S �� PS PS PS
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6. SOILDRAINAGE/GROIJNDWA'IER �S S S S
(EXTERNAL&INTERNAL) rYSJ IU'%„e.Jf� pS . PS PS
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7. SOIL PERMEABILI7Y S S S
(PERCOLOAT'ION RATE) � PS PS PS
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R. AVAILABLE SPACE $� �., � S S S
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9. SiTECLASSIFICA710N(SEEBELOW) �
SOIL SERIES
S-SNTABLE PS-PROVISiONALLY SUITABLE U-UNSUI7'ABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.� C:V�MIPRO�DOCSIAPPSEC.SMFINANCE.PC
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PERSON COUNTY HEALTH DEPARTl�ENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # � �'Z Parcel # �a .3
Zoning Township O l �" ve �i"l �
Owner/Contractor � , Date `7— /3- g�"
Location/Address
!.-� rn�° '1rJ^vZ o �':# -�% ''�-l-�,
Subdivision Name oo ' s S Lot# ��
As Installed
Layout
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SEWAGE SYSTEM SPECIFICATIONS
Repair . Lot Area�Gv� Size of Tank S�
SFD Mobile Home Size of Pump Tank �
Business # of Bedrooms Nitrification Line �� �,�(3 �
Max Depth Trenches_.? �'� '
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is
Well and Septic Layout by
Comments:
C532
�Well Permit Paid� WELL SYSTEM SPECIFICATIONS
Individual_�Semi-Public Required Slab v
Public Replacement Air Vent ��
Site Approved ✓ Required Well I,,e� Z'l
Well Head Approved Well Tag �
Grouting Approved� � 2'l'��0
Comments:
Installed by i�111 ��� Approved by,
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. The
environmental health specialist is not responsible for false or misleading information contained in the 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 Person County nor the environmental health specialist warrants that the septic
tank system will continue to function satisfactorily in the future or that the water supply will remain potable. r.�amipro\permit.sam 01/95 rev.1.0
�- • ' . PERSON COUNTY ENVIRONMENTAL HEALTH �
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�.� � WELL LOG �
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Date: �� - �� z�'v '
Owner ,�3�°« �������nrr � SR# ' � .
Location/Directions: ��'` ��� %��� �s�N:� �;�r � �
Subdivision Name: __ Qo��o :// Lot # /�
Drilling Contractor: � � �c
WELL CONSTRUCITON
Distance from Nearest Property Line I v Distance from Source of
Pollution f G �
Total.Dep.th: �SD Ft. Yield: S GPM Static Water Level o2.S—' Ft.
Water Bearing Zones: Depth /�D F[. SD � F� � Ft� Ft.
Casing: Depth: From 6 to�Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel
IF Steel, does owner approve: Y�s No
� � Weigh� Thickness:� '� Height� At�ove Ground: I�i Inches
Drive Shoe: Yes ✓ No �
Were Problems Encountered in Setting the Casing? Yes No � �
If "yes" give r�ason:
Grout: Type: Neat Sand/Cement / Coricrete
Annular. Space Width � Inches
Water in Aimular Space: Yes No
_ .. Method: Pumped � - Pr:ssure � � Poured � � - � - -
Depth: Fr�m O to �.O F�
Materials Used: No. Bags Portland Cement Weight of .1 bag lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes � No � � � �
� 4 x 4 slab Yes i No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON CO'vi�ITY HEALTH DEPARTMENT.
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Sig aturc of C ntractor Da�c