A28 15PERSON COUNTY HEALTH DEPARTMENT
SEWAGE DISPOSAL
IMPROVEHENTS P�T �O ' -
Issue Date: /' �
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Owner:
Location � _ �
t
Septic Tank Contractor: O
Building Contractor:
Water Supply: Private Public
All wells should be 100 f-t. from sewer system.
Lot Size: f�aL
Sewage Disposal/ Facilities No. bedrooms
Size of tank: / D �� �A Nitri ica��ion line:
Other disposal fac
Water supply and sewage disposal facilities location, installation and
protectiion must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be
maintained by owner in such a manner as not to create a public health
hazard. Septic tank and nitrification line MUST BE INSPECTED AND
APPROVED BY A MEMBER OF THE PERSON CO. HEALTH DEPARTMENT STAFF BEFORE
ANY PORTION OF THE INSTALLATION IS COVERED AND PUT TO USE. THIS
PERMIT VOID AFTER 3 YEARS.
Date Well Approved:
By:
Date Sewage D"sposal Approved:
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By:
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Signed /.�• Q.
S n tarian
Counter- � �
signed
(Own o re esen ve)
/
Certificate of Completion
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Date Approved: � � By: � `r�.
Sanitarian '
(Over)
Location of well and sewage disposal facilities sketched on back.
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WELL DRILLING
Baffa�o Jima,� V_u� �b:�
WELL PERMIT
Casvell-Chatham-Lee-Peraon Cotu�ties
DATE ZSS�D: �ATE DRILLED: � 0 O�D/S � TCOU�
OWNER: �� � n�l� L
NAME
WELL CONSTRUCTZON
Distance irom Nearest Property Line � Distance from Source af
Pollution
Total Depth: Ft. -Yield: GPM Statie iiater Level: FL.
water Bnazing 2ones: th• Ft. Ft. FL.
Casing: Depth: From .to PL. Dia�ers lnches.
TYPEe Steel Galvanized Steel
Zf Steel, does ovner appr Yes Mo
MeiqhL: Thickneas: Heigai Above Ground: Iaches
Drive Shoe: Yes: No:
Flere Pzoble� Encountered in Setting tbe Casang? Yes No
Ii 'yes' give reason: � —
Gront: Rj�pe: Neat Sand nt: Concrete
1►anular Spnce Midth �Inc.des
water ia Annular Space: Yes No
!lethodz Pumped sure Pouzed
Depth: Froa to � FL.
Materials Useds No. Bags Pvrtlmd Ceaeat lieiqht of
1 bag lbs.
Zf mixture (sand.�ravel. euttinqs) - Ratior to
ZD Plates: Yes�No Chloriaation: Yes No
4 z 4 slab Yes No
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2 i�REBY CERSTF7 SHAS THE 71HOVE INFOitlSJlTION ZS CO 11lID SSAS TfiZS
FTELL h1A5 CONSTRUCSED IN ]1CCORDAN Z REGIJ OKS F'OR2ii H7
CASitELI.-CHATHII!!-LEE-PERSON D2ST.
. S gaature of Caa:ra Date
FOR HEALTH DEPARTHENT USE ONLY
REASON FOE !10 IKSPECTIOH:
. Saaitarian's 5lgaature DaLe
Sketeh �rell loeatina on.reverse side_ Use esLabliahed reiereaee
poiau.
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�, S� °IZZ� 3 I�-9�
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�` e APPLICATION FOR SERVICES
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5ervic�es R+equestec� ��.:� � _
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Improvements Permit (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing)
Improvements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
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Permit (Mobile Home Replace)
Improvements Permit (Addition)
Permit for New Well
ace Existing Well
.;:,: .,. ::. __ _
Bacteria � Chemical Petroleum Pesticide _ Lead
Permit requested by: �'e�r�� Z�b`� 7. Dimensions or Proposed Structure: s i N 1 Q_ � d�
ner/prospective owner/agent:
Width: �� 2e p l a c.e
dress: � a � � �
; Depth: �,�-- w� � do�.b 1 e�� cl
;Q,` 1���{� f1T�,''� S'7 3 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 #:,�599' 0�`6�
usiness Phone #: ��1q'4I l�� �. w � ���
. Name and address of current owner:
: Lot size: 1�, 5 q���5
Tax Map#: A � $
Parcel#: � S
Township: 01 i v e: �� 1 �
Directions to property: State Road #& Road
ames, etc. _
Number of occupants or people to be served:
9. Water supply type: ,
private�ublic ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No ❑
If so, identify location:
10. Type of structure/facility: Proposed:.�xisting: ❑
Type of dwelling:
House: ❑ Mobile Home: ❑ Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: 3
Garbage Disposal? Yes ❑ No �
Basement? Yes ❑ No If so, # of basement fixtures:
F'LEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTZJRES.
I hereby make application to the PersOn COunty Health Department for a site evaluatiun 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.
igned Owne�r Authorized Agent
Permit Issued ❑ Signature
Permit Denied ❑
Plat Observed ❑
Date
` '• FACTORS-SIIE'�'A1-17AT10N ;: `
__.., _ __ _. __....._._ ` ..... <.AR!'�S,t > ';;AREA2 ;;' . AREeC3 AREAd :
_ _ .. ._._
l. SIAPE (%) S S S S
PS PS PS PS
u u u u
2. SOQ.7'E?CNRE(12-36IN.) S S S S
(SANDY. LOAMY. CLAYEY. NO'IE 2: t CLAY) PS PS PS PS
U U U U
3. SOiL STRUCIl1RE (12-361N.) S S ' S S
(CLAYEY SOII.S) PS PS PS PS
U U U U
4. SOfLDEPTFi(L�f.) S S S S
PS PS PS PS
U U U U
3. RES7RIC77VEHORIZONS(iN.) S S S S
(AIPERVIOUS STRATA. ROCK) PS PS PS PS
U U U U
6. SOII. DRAINAGFIGROUNDWATER S S S S
(FJCiERNAL & IN7ERNAL) PS PS PS PS
' U U U U
7. SO(L PERMEABiLITY S S S S
(PERCOLOATiON RATE) PS PS PS PS
U U U U
8. AVAI[.ABLE SPACE S S 5 S
PS PS PS PS
U U U U
9. St7E CLASSIFlCATION(SEE BELO�
SOII. SERIES
S-SUITADI,E PS-PROVISIONA[.I.Y SUifADLE U-UNSUITABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.) C:WMIPRO�DOCS�APPSEC.SMF[NANCE.PC
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT
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 # %'� � Parcel # ��
Zoning Township UI i v e i
Owner/Contractor �c.�"��p v�If {� v' Date 3�%S- ��_
Location/Address
Subdivision Name
Lot#
S.R.#
SEWAGE SYSTEM SPECIFICATIONS
'� Repair Lot Area /�, �S"�; c��s Size of Tank S�
SFD Mobile Home Size of Pump Tank� "
Business # of Bedrooms___�__— Nitrification Line__�
�� 1,. _�.,� �/r. i nn u„i-� n InIM {� Max Depth Trenches �,� _
� . ,,., , .
a
v Permits may be voided if site is altered
� Well and Septic Layout by i
a Comments:
Date .3� � �-`� � Installed by � � a� Approved by
Well Permit Paid ❑ WELL SYSTEM SPECIFICATIONS
ell
Comments:
Date 1v\lv � Installed by.
Required Sl
Air V�t�
Well
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
H 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
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: �-I.� i�o IlVg'ROVEMENT PERNIIT #: Q
TAX MAP #: PARCEL #: ��
OWNER/OWNER'S REPRESENTATIVE: .���r�e�/ �V%> >/
LOCATION/ADDRESS:
r
W � i�l S�� �" LOT #: 3-�
SUBDIVISION NAME: � C�
SECTION OR BLOCK:
AUTHORIZATION FOR CQNSTRUCTION ISSUED BY:
AUTHORIZATION CONDITIONS
1. The Wastewater system construction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Permit # Q 0/ g y. The
construction and installation must also meet all applicable rules and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any alterations in site or soil conditions (including structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authorization and associated pernuts.
4. Conditions:
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hn ��� � �,O �-e � � �, �1� c��e
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Person Requesting:
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s�t�ic �+^�f•