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1. Permit requested by:
owner/prospective own�
Ad�ess: � � pp
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ome Phone #:�
usiness Phone #:
. Property
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Parcel#:
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Chemical �
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r/agent: 1
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Petroleum I = Pesticide � _ Lead
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7. Dimensions or Proposed Structure:
Width: � p
ilPnth• ��O
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal s stem is intended to serve?
�/U � N �`� ��.J O c.v ,•�
ress of current owner: ' 9. Water su�zply"type: �
D N� private �� public ❑ community ❑ spring ❑
.�} �'•� Are any wells on adjoining property?Yes ❑ No ❑
�.,l9 ��' . 2_ ? S�3 If so, identify location:
Description: Lot size: �-1 ,<o b o� Ero
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. Directions to property: State Road #& Road
iames, etc. I �N
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10. Type of structurelfacility: Proposed: DExisting: ❑ I
Type of dwelli .
House: obile Home: ❑ Business: ❑
Type of business: N %i
Number of Employees:�_
Number of bedrooms: �
Garbage Disposal? Yes ❑ No ��
Basement? Yes ❑ No 0'If so, # of basement fixtures:
�6 Number of occupants or people to be served: � �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND 1'HE CORNERS OF ALL
'PROPOSED STRUCTURES.
I hereby make application to the Pei'SOn COUI1ty Health Departmerit 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.
. a
,' e��Ow er or " utho ' d A-ent
permit Issued LI�
Permit Denied ❑
Plat Observed LY
Signature �(-C Date
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1. SLOPE ('.F) ; S S S S
PS /*� y PS PS PS
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2. 5011.7'E?:7URE 112-36 (N.) S S S
(SANDY, LOAMY. CLAYEY. NOTE 2: � CUY) PS �� PS . PS PS
I- U U U
3. SOIL S7TtUCTURE (12•161NJ S^ � S " S S
(CLAYEY SORS) PS PS PS
U U U U
3. SOiL DEfI'Fi (IN.) ` S S 5
p5 // t� ps PS PS
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t, RESiRICTIVEHORIZONS(iN.) S S S
(IMPERVTOUS STRATA, ROCK) , � � �Ip � � �
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6. SOII. DRAINAGFlGROUNDWATER �/%- S S S
(FJCTERNAL r4 Qt7ERNAL) N D lN.o// � PS PS PS
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(PERCOLOATIONRA'IE) S' � 3AYL PS PS PS
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9. SiCEMSSIFICATION(SEEBELO� S
SOII. SERIES
SSUITABIE PSPAOVISIONALLYSUi[AHLE U-UNSU(TABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
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. S�APPSEC.SM FlNANCE.PC
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SITE PLAN
STEVE WALLACE
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• PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
;,
Tax Map # :� r% Parcel # r%�
Zoning Township /,'//e f i /�
Owner/Contractor -�e,.�-� I,��t 1 � � � �' f-� r ,��, /'e " Date � - ,.�� - ���
Location/Address S'� ��Jo,-� � d� �'n-t��;�e f�r��✓G ►-+,.,1:,�
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•S.R.#
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Subdivision Name Lot#
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SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area p0�� , Size of Tank ���� �jll�„ .r
SFD Mobile Hom Size of Pump Tank ,�; �
Business # of Bedrooms�_ Nitrification Line 1.,c�� � X.��
Max Depth Trenches ��
Permits may be �voided if site is altered o
Well and Septic Layout by �
Comments:
use �hanged.
Date $� / Installed by `��t�►�.t �.-Lc.�JYo APProved by
�-�s�'
Weil Permit Paid ' WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab
Public Replacement Air Vent '
Site Approved Required Well Log _
Well Head Approved 3 Well Tag
Grouting Approved j < -
Comments:
Date
Thi�. � ..-i...� � �.. ...�..�_ _ I-^- - -- a
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.
c:\amipro\permit.sam O1/95 rev.l.l
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SITE PLAN �r5-i� �-� ���
S TEVE WA L L A CE ������Z �g���3�
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❑PERSON COUNTY HEALTH DEPARTMENT
355A S. MADISON BLVD.
ROXBORO, NC 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant h� .�%�i i�2
Address 3o Gran��e. �r. County�vrson
Collected By TS
Date Collected �- �- �J9 Time Collected /: ZS
Source: Q" Well ❑ Spring ❑ Well Tap ❑ Other
❑ No Charge C�3'Charge
9c�F9c�9cx9c*�c�'cxxicic*�Fx�c�c�kx*�9cic�cxx*x�'c*�**�cic�'cic�F�'cic�k�'cic�kx�**�FxoFdcx��c9cicicicxx�**xx k*�c�F
*�'c*��c�F��9c�'c*�"c�c�c9c9c9c�k*�F*�c�k�F�k�e9c9cak��k*�F�+c�c�k**k��'c*�F�F**9c�c**�F*�c*�'c9c�k�F�: k*9ca�:r**�c**9c9c
Results
Present Absent
Total Coliform 0 �iY
FecaVE. Coli. 0 D�
Reported By
D�te � �� � (��
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Ct� Steel, cie>e.s u�vner a����rc�vc:: Y�s Nu -�--------�----
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1)rive Sl�i��: Y�s--------- �1c� - _�_ .
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ll �yes� �tv� I�t�Sc>ti: __..._-•- ---
Circn�t: ���Yl�: Nc�it.._..._ ------ Ssii�<1/r:u�ii�iit ---`-----�,c��ic:r���-------�--- -- ,
Anriular S��acc Wicitl�--- 1n�lic;S_l.....___..._.. .---- --
Watc:r i�i Aniiular S�>��cc: �'�s -------- Nc�
Metl�c�ci: Pu�r��x:ci--------- l'ccsstiic;^-- -.__(�uur�cl
Ue��tl�: 1=rc�tf�-------------- ic> ----- r�- ------
Ma[c:rials Usccl: i`jc�. I3abs Pc>rtlanci Ccntciit tiVei�;ht uf 1 hab ll�s.
If mixture (s.in�l, �;ravel, c:uttincs) - Ratir�: �c� ---�
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