A28 57Person County Health Department
Sewage System Improvements Permit
; Date:� Tiiis Pe it V' After 5 Years Pemiit #
; pwner: .-�•� u � /�� V i,'i SR# �
' Locadon/Uirections: er� SQsPph H*.�s o.
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Subdivision Name: �'1 ti. . Lot #
Lot Size: -�. n'l r{/PS Type of Dwelling: `
Water Supply: Private: � Public: Community:
Bedrooms: Gazbage Disposal
��, Bas�mei�t Basement Fixwres
INFORMATI4� BY
i � ownu or teptesauative
Sanitarian: ; 1as-� -
REppIR: VALiJATION: `� " `
Size of Septic Tank: �QQ� gallons S,i�e:of Pump j�'aiilc G �'
i Nitrification Line: ��Z� X 3 i� ��R_
' Depth of Stone: 12 inches
' Max Depth of Trenches: t�` -
Altemative SystFrn: Conv. Pump =� LPP Pump w_� ,r
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Date Well Approved _ �Well should be 100 ft firom any sewer system
BY _ ; :Sanitari�n
Date Sewage System Approved
BY Sanitarian
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CERTIHiCATE OF COMPLETION � �
; Contractor. �
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Sewage System location, installation, and protection 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 manner as �t to aeate'a public health hazard. Sepdc tank and #
nitrification line must be inspected and approved by a'member of the Person County
Health Departrnent before any portion of the installauo.n �s cov� and put into use. If ��
. the site plans or interded use change this pernut is sub�ect to revocation. �.
' (G.S. 130 A-335F) ' '
_ :: � - -
�, Locaaon of sewage disposal se�age system sketched on back. (� �" :
(OVER) �
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Site Evaluation Application Date:
Fee Collected YES � NO
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APPLICATION FOR IMPROVEMENTS PERMIT
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1. Permit requested by:
Address: � � S
Home Phon�' `��' : �
2. Name and address of c
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owner/prospective owner:
�„ f agent:
'�_ Business Phone 4�:
�
t owner: i /c�Sr'�fi C-
3. Property Description: Lot size: � At'�E�j'
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(� 2 � `� 2-- • .
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4. Tax map ��: Township: 6C/U� Jf- GG_.
Subdivision Name: _�--��r ����� ���_�r� � Lot ��:
S. Directions to property: State Road �� & Road Names, etc. �
a F� t3C.ALoC'fC ��-�1��1 P.s�Q_ .Co-� `-
SS
6. Permit requested for: New Installation: � Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served:
8. Dimensions of P.roposed Structure: Width: Depth: '
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?
10. Water supply private? � public? community? spring?
Other source? (Specify):
Are there any wells on adjoining property? ��`' If so, identify location:
11, 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
Basement? Yes No 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 issue. Permission is hereby granted to
enter the property for the evaluation. G.S. 130 -335(F)
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Sig d Owner or thorizen Agent
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Permit Issued ✓
Perm3t Denied
Plat Observed �
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i?ACTORS - SITE EVALUATION
.
1. SLOPE (X)
2. SOIL TExTURE (i2-36 in.)
(Sandy, Ioamy, clayey,
Note 2-1 clay)
3 SOIL STRUCTtTRE (12-36 in.
(Clayey soils)
4• SOIL DEPTH (in.)
5• RESTRICTIVE HORIZONS (in.)
(Impervious Strata, rock)
6. SOIL DRAIIQAGE/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�II�21DATIONS / COrIIiQITS :
S�TE CLASSIFICATION DIAGRAM (IncLude: Soil areas, property lines, roads, streams, gullies,
wet areas, fill areas, Wells, water bodies, slope patterns, etc.)
Antoun,t paid ��a'
Rece}�t' li ` ��00
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av
�d � �a�. ��� � �
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1, permit requested by: .
owner/prospec�ve ownec
Address: • 1 - °
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7. Dimensions or Proposed Structure:
:I��ann `�� rv��.S __ Width: 2. �' � G�
�— Depth: '
� 5� 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 #: � 5 � 9 ` ���
usiness Phone #:
owner: 9. Water su y ty pe:
^,� Qs private public ❑ �o�unity ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No j�:
If so, identify location:
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Name and addre&s of
. PropertyDescription: Lotsize: � aerrs
. Tax Map#: � � � L� ��
Parcel#: � y��-
Township' �� �� �
i. Directions to property: State Road #& Road
. Type of structurelfacility: Proposed: C�Existing: Q
Type of dwelling:
House: ❑ Mobile Home: usiness: ❑
Type of business:
Number of Employees:
Number of bedrooms: y—
Garbage Disposal? Yes ❑ No � xtures:
Basement? Yes ❑ No�-I�o, # of basement fi
6. I�Iumber of occupants or geople to be served:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTIJRES• �
I hereb make a plication to the Pex'SOn COUIIty Health Depal'tment for a of th s auali�atf on ahe �e ite
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sewage disposal system for the above described property. I agree th I�understand if the site Psaltered or the
and represent the maximum facilities to be placed on the propecty•
intended use changes, the permit shall become invalid. I understand that before an�i hat in the event have note
issued, I must presen[ a survey plat of the proper[y to the Health Dept. I understan
delivered a surve lat of the property to the Health Dept. within 60 DAYS after th fe �ed of the evaluation of
the site by the H alh Dept., this application shall become void and all fees pa�d fo
Signc� wner or Authorized Agent
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMI'ROVEMENT 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 # � 2� Parcel # �1%
Zoning Township �� u� ; �
Owner/Contractor 4�. ,rn Date -
Location/Address S l aG K ` � n
Subdivision Name
S.R.#
Lot# �`-`�j
SEWAGE SYSTEM SPECIFICATIONS
[�epair Lot Area S.pO }�C- Size of Tank (�O� �� �''�/l.0
SFD 1/ Mobile Home Size of Pump Tank
Business # ofBedrooms�_ Nitrification Line � �C�'
Max Depth Trenches %� `�
�c.�/�fv ��4�t �
Permits may be voided if sit Itered or
Well and Septic L�out by
.,`.,.—
Date - - Installed by Approved by
Well Permit Paid WELL SYSTEM SPECIFICATIONS
Individual �/ Semi-Public
Public Replacement_
Site Approved _ �� �
Well Head Approved -
iV�i...4irR I�r�r�r���n� . . ���
Required Slab �
Air Vent �/
Required W� Log
Well Tag �
Installed by (�VI{��i-�' Approved by.
This report is based in part on i�formation 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.
c:\amipro\permit.sam O1/95 rev.l.l
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I.�rillin� Cantraccor:
BENNETT WELLDRILLING
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PERS�N COUNtY �N�'1 RQNMf;'T � 1, K�A1.TF
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Ihi�� Shar.: Yes_�/ Na
tiVere J��bi��ms Encauntered in Settin� i.he C':esinR? �'c�s _-.....N� �
Ir ''} c5" git•c r�.asan: —
t�rc�ut: �1�Y}�e: �fett--- 'i � Sanc�lCement __ , +:~n�c:retC
fir�nular Space Widlh_..._,�,�_UcfiCs
1Y�ter in Aru�ular Space: 'Yes� _ No_c� _
Mc thad: Ptunped_, ,� Pressure ._�, Po�u �.� ✓
I)cpch: Frcun�--v--� to,. � U� Fc�
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Materials t)sc��: N�. $ag� Ponland Cemer��,.��, ��'e;�t,� Qf z ra� �%�3 lbs.
If n�ixture isand, gravel, cutting5) - I2atio:_____ ��._�
iU Plates: Xcs�.�.,,,,�„ No,� �"
4 x 4 slab Ycs�...� N��
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From .__ ,�J ,.'._� , Form�tion Descriptiort
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