A28 171- �erson County Health Department
�ewage System Improvements Permit
Date: � This Permit Voi Aftet`.i Y�e�a1r€ Peimit #��
OWII�r'� ' �L�� 4�t � � ' � 1�1�1 SR# f/ S
1 rratinn/Iiirnrfinne• . _ � n . _ _ . .. . � GFf �"�dt�INl
Subdivision Name: Lot #
Lot Size: Type of Dwelling: �
Water Supply: Private: Public: Community:
Bedrooms: Garbage Disposal �
Basement Basement Fix
INFORMA D BY
$NI1t�7t18I1: owner or �entative
REPAIIZ: REEV ATION:
-------------------------
Size of Septic Tank: _�� gallons Size of Pump Tank:
Nitrification Line: !1/%/J � 'f�_3 �
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: /�Co�nv/y ��Pump nLPP Pump
RCuW11�J: /�.t' /v}.F2 / _ (� B ///'i �"f.� ,� C'12�5%A7 r
______ �_________�s______�
Date Well Approved: �-j� 9L Well should be 100 f� from any sewer system
BY !��_ Sanitarian
Date S y Approv : - -
BY Sanitarian
CATE OF COMPLETION
Contractor. �
Sewage System location, installation, and protection must meet state and local
regulations. Septic tanlc should be pumped out every 3 to S years and 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 approved by a member of the Person Counry
Health Department before any portion of the installation is covered and put into use. If
ihe site plans or intendeci use change this permit is subject to revocation.
(G.S. 130 A-335F)
Location of sewage disposal sewage system sketched on back.
(OVER)
�
�
Person CouMy Health Dept
�� 325 S. Morgan Stre�t / c�
A"in o u n t p a i d I d D• ROxboTO, N.C. 275% 6 a��� 1.
�cceipt IE ' 0 0 OZ
�qurier �2•33-16 D a t e
�� a�� L APPLiCATION FOR SERVICES
X.,S�: s �s fin "ui� . a�t�.L. .�k,`� tfa3g�� a �:��y a"��.-�;1-:t^� � �e:° fJ'ai.i�'•'°`,rix.��wS�.i,��.'."0� � �"k�.a�'f x ) • V + '' '�wc° '�ri� --.��i ��•£.}.�t'�'�'�'�`3,,.'�'':�� ���''
d'N,�.3'��a.>44�f y .� wt ���'" `���bB,�aX� �•-ytS�C°t��i�^�'`� �Serv�ces;Reques�ed K .y, � t'��.SiA�'�3&�:d's;t�o.+s.. a.:+aA�� �
• � '�' erSw.., a.<ti.,�.>,Fa.,.sx[':�x.+.�-r aL..:i&..L.,. c .�'�."e �,w.cr.«.N�".:-. ,,. ..�+.,..Sr>.m. � . �w.,.u�..,...x.-.. r .. _ � '�"
e."�s'r.r .�.av.�.r:A••• < x
w_ Improvements PeRnit. (Established/Recorded L.ot) _. Reinspection of Exis[ing System (Loan CIosing)
�
H
O
�
�
�
w
U
�
a
¢
�
�
H
c1a
�
z
vements Permit (Unrecorded Lot)
ts Permit (Mobile Home
Improvements Permit (Addition)
_ Bacteria � _ Chemical
lace)
RepaidReplace existing Septic System
Permit for New Well
_. Replace Exis[ing Well
_ Petroleum � _ Pesticide � _ Lead
1. Permit requested by: . 7. Dimensions or Proposed Structure:
owner/prospective owner/agent: ��Nvau. 1'S• SNiTN Width: 5� �
Address: l21 S1"�►=c�-►-N►�.�. L.At�lE Depth: yo'
tZo�C3oPv 2?5 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?
Home Phone #:�33c.� 5�i?- `37 37 u�N�
usiness Phone #: C9�q) 8`FS-�`l'1`l
2. Name and address of current owner: 9. Water supply t}'pe:
SAME AS �" private �j . public ❑ community ❑ spring ❑
� Are any wells on adjoining property?Yes � No �.
If so, identify location: �22oP�r/ oF
3. Property Description: Lot size: I► D AG�S �'�a� �� SM�-r+a DP� 2i7 P los
. Tax Map#: .�'� 10. Type of structure/facility: Proposed: �lExisting: Q
Parcel#: � Type of dwelling:
Township: 61, V� .�. � I' House: �1 Mobile Home: C� Business: ❑
5. Directions to property: State Road #& Road Type of business:
ames,�tc. Number of Employees:
Le�u,u, R�o �tw�r �58 w), Tiaic.� t,EFr ou,a FS��.ouc. Number of bedrooms: �_
AlI2y RD (sx 1i58 TAC& R��GI�T oAt7� DR��`fIAN�� (LD Garbage Disposal? Yes ❑ No �
���r a�rv s�n�r�+ �+iu- �u. �lvo ' a� t,x�r. Basement? Yes ❑ No�S! If so, # of basement fixtures:
6. Number of occupants or people to be served: .�_
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND "1'H� c:Vx[v�;x5 ur aLL
PROPOSED STRUCTURES.
I hereby make application to the PerSOn COunty Health Department for a site evaluation for the on-site
se�vage disposal system for the above described property. I agree that the concents 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 shatl become void and all fees paid forfeited.
Signcc� Owner or Authorized Agent
��rson Gouraty Heal�h Department �
Vllell Perr�it �
, �
Date: �� 's Permit Void A�ter 3 Years �,� � 'ti
Owner:
-' ' � `�� � T� SR# I; ."� �� �
Location/Directions: � �� i��-� +��•
LJ �� £
Subdivision Name: Lot #
Drilling Ceniractor: �.— � �'� :� -. + - - � � !� ,
WELL CONSTRUCTION ►�
1�istance from Neazest Froperty Line,� �' z'` �>..:�,� Distance from Source of �'
�olludon !i ' � — �
: `:
'I'otal Depth: ��i ` � Yield: ��_uPIV� Static Vdater Level � � Ft. �
�Nater Beanng nes: Depth ,[,3.,� F:. �� F� F� Ft.
Casing: Depth From �s� tc ,� i� F� Diameter: ��_ Inches
TYPE: Ste.�l � L�� al� d Steel =�' i
If Steel, does owner approve: Yes No
Weight: . � Thiclrness: ��; _�''-Height A�ve �'rround: _.,� Inches
Drive Shoe: Yes �'� I�To
Were Problems Encoimtere3 in Setting the Casing? Yes No
If "yes" give reason: `b
Grout: Type: Neat Sand/Cement � Concrece �
Annular 3pac� Width � Inches
Water in Annular Sgace: Yes No z—'�" "
Method: Pumped �essure Poured �..---
Depth Fmm == to .2- � �
Materials Used: 1Vo. Bags Portland Cemen � Weight of 1 bag
� � lbs. '
If m'vciure (sand, gravel, cuttings) - Ratio: '� co �_
ID Plates: Yes �--'r.� I�to b
4 x 4 slab Yes �— I�Io �
RILLING LO� �,
Depth __ .�
� HEREBY CERTiPY THAT THE ABOVE INFORMATION IS CORRECT AND_THAT
THIS WELL WAS CONSTRUCTED IN ACeORDANCE WITH REGULATIONS SET
FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT.
^
�'� ��. ..��1_,.�, ;�,,.� ,����,��� .�r � ���.
� �� ; f ; � ��� ; � ature-�f �ontra�tor ' Date
Y � � g ' � y..
' . � , r �� F t J� , �� ` ._ y� fi ,e.� �!a
�,�- ��.�' , > ,: ^" ���� ' '� g� - � �. �
�y
. (.�'�',�`+ ��.� ����"�`'� Sanitarians Sig �ature Date Issued
���A ' '
� : �"�
' Sanitarians Signature Date Completed
Sketch well location on reverse side.
1
Person County Health Oepartment
�:xisting SeNage System Report For: ✓ Hobile Hocne Keplacement
Addition
- . - - ;/. I,/, / _Ii II/
� �/ ■ � _
�� /� � �.
Home Phone#(. , ) 97-�f%�J%
BusinessTM / �� �
'Pax Hap# 'i� �
. _ . - . r�i4:.�(�R��:!s.i�iir�►��.--z:��
Original Perm�t Located ..
Septic System Uesigned For: _
Kesidential � Business Other (specifyl
# I3edrooms J � �;mployees Other
llate '1'nstalled � �- Water supply i�
Type ot System WI�`V��Y%(�t
Nitrification Line �l�,C d�
Tank Size UU
, Certified Operator Required fV/�
On site kastewater disposal system showes no visually apparent
malfunction on 1�{rlb~��
Yermission is granted to: W1��G` �� �S��L L�l -
According to the attached site plan.
Comments:
Environmental Health ��.
DATE
`�C�Q �
0
l
.���;;�::>::�:
� V
�
�
�
M
� �
. .` �
, �`z
�Q � s
, ,
� /1 � '`
� `
� �
�
�
�
��
•se,�
.
��
�
�� ��
�
• Oz�
�
� ` .�
�
�
\ ` •'`
�
�
�
� •
�
�
�
�
�
���
�a��, ,
,, ,
� �
�
Z �� ��`
�
�
,9t.8��` ```� a
.� � � ,� �I
�
�
�
�� � `
`�`
� •