A28 78..,.
Person Count
: �Ser�rage System
Date:�7'� ���s Permit Vqid
Owner: �-Q r11� �l ,� WCn
y Health Department
Improvements Permit
5 Years , Permit
Subdivision Name:
Lot Size: ,' Type of
Water Supply: Private: —� Public: _
Bedrooms: � Garbage Disposal
Basement Basement '
INFORMATION CERTIFIED BY '' '
Environmental Health Specialist:
REPAIl2: REE i7ATI0:
Size of Septic Tank: �v gallons �ize of Pump�Tank:
Nitrification Line: t' � i'N l r'
Depth of St�ne: 12 mches � ySa'� �2`�
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks: -
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Date Well Approved: -S' �'�3 Well should be 100 ft from any sewer system
gy 2r� Environmental Health Specialist
Date a e ys m App ved: ��- ��`I -3
gy Environmental Health Specialist
TIFTCATE O COMPLE;TIO ,.�
Contractor. C' }'1 Y�'�/ �,� v✓ �(') o ' �
--------- --f� �P.r �
------ �
Sewage System lceation, installation, and protection must meet state and local �
reguladons. Septic tank should be pumped out every 3 to 5 yeazs 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 County `�
Health Department before any portion of the installation is covered and put into use. If °a
the site plans or intended use change this pernut is subject to revocation. �
(G.S. 130 A-335F) � �
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L.ocation of sewage disposal sewage system sketched on back. �->
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(OVER)
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ota NoR-ria �-�Tc 1�c��s
� ` f�erson County Health Department �
. Well Permit �
D'ate: 2- Z-aZ This Pennit Void After 3 Years � f�
Owner. �.C, h„�� 2 l.�%G� rt oiti. � G� �t s ����
Location/Directions: �`'�s
Subdivision Name:
Drilling Contractor'if�� �� w���' d�a �w .4. N`
WELL CONSTRUCi'ION
Distance from Nearest Property Iane Distance fiom Source of
Pollution
Total Depth: t Yield: ��GPM Static Water Level FG
Water Bearing Zones: � Ft. FG�.�Ft.
Casing: Depth: From to Ft Diamete;: �_ Inches
T'YPE: Steel Galvanized Steel V
If Steel, does owner approve: � No
Weight: Thiclrness: Height Above Ground: Inches
Drive Shce: Ycs No
Were Problems Encountered in Setting the Casing? Yes No
If "yes,� give reason• f,�
Grout: Type: Neat San ent Concrete
Annular Space Width � Inches
Water in Armular Space: Yes No
Method: Pumped Precs��� Poured '�
Depth From � to G�J F�,
Materials Useci: No. Bags Portland Cement Weight of 1 bag
lbs.
ff m'vcture (sand. gravel cuttings) - Ratio: to
ID Plates: Yes � No
4 z 4 slab Yes —�– No
I HEREBY CER'TIFY THAT THE ABOVE WFORMATION IS CORRECT AND THAT
'THIS WELL WAS CONSTRUCTED IN CCORDANCE W1TH GULATIONS SET
FORTH BY THE PERSON COUNTY P
�,�� 2-1��3
S' f Con tor Date
�`� D°� Cli � � �Z � z
Sanitarian's Si ture Date Issued
�y ((,p,,., ou���
1
Sanitarians Signature Date Completed
Sketch well location on reverse side.
NOTE: Make sketch of installation showing lot size and shape. location of house, septic tanks, privies. water
supplies,• etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots.
(1) (2)
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Site Evaluation Application
,
Date: l �/� �/��C�
--� .
� Fee Collected YES ,� NO
l03. o0
ti--�- -
�a _ a a � 9� APPLICATION FOR IMPROVEMEPTTS PERHIT
�� �G� / !o �
1. Permit requested by: owner/prospective owner:
,.� a�ent:
Address: �� a( �8`�
Home Phone ��:
2. Name and address of current owner:
Business Phone ��:
— ����3 .�
3. Property Description: Lot size: �, p��,
4. Tax map ��: �1" �� ��$ Township: ��� y-.`
Subdivision Name: �Q ,�(�� . �l�raa.,��� Lot ��:
S. Direction� to property: State Road �� & Road Names, etc.
��ti/1,,�.e�.: ; .S'� L./� .i M � !e.-� T� �z�,o /.C�-iz �•n-r<�-r
6. Permit requested for: New Installation: � Repair:
Additional Renovation re-using present system:
7. Number o£ occupants or people to be served: �
8. Dimensions of Proposed Structure: Width:
Depth:
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m
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? �
H
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x
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10. Water supply private? �j public? community? spring? �
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Other source? (Specify):
Are there any wells on adjoi
11,
property? ti If so, identify location:
Type of structure or facility: Proposed: ✓ Existing:
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, 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. OA 5(F)
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� igned Owner or Authorized A ent
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Permit Issued � � � � � -�� �
Permit Denied
Plat Observed I/
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rACTORS - SITE EVALUATION AREA 1 AREA 2 AREA 3 ARFA 4
1. SLOPE (X)
2 . SGLL TEXTURE (12-36 i.n. )
(Sandy, loamy, clayey,
Note 2:1 clay)
3. SOIL STRUCTIJitE (12-36 in.
(Clayey soils)
4. SOIL DEPTH (in.)
S. RESTRICTIVE HORIZONS (in.)
(Im�ervious Strata, rock)
. SOIL DRAIIZAGE/GROUNDW
(bcternal � Internal)
. SOIL PERMEABILITY
(Percolation Rate)
$ . OTEIER (specify)
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9. SITE CLASSIFICATION
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
RECO2giEEI1DATI0NS /COP44ErITS :
SsTE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines. roads, streams, gullies,
Wet areas, fill areas, Wells, water bodies, sZope patterns, etc.)
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