A28 79z
,�c��son County Heaith Department �
�ewage System Improvements Permit
Date:�3-9� This Permit id After 5 Years Permit #�f{Z2 -
Owner: C � ✓ ( ��YVQ r ���
L.ocation/D'uections: ¢,i--�-T—
Subdivision Name: Lot #��
Lot Size: Type of Dwelling:
Water Supply: rvate: Public: Community:
Bedrooms: � Garbage Disposal
Basement Basemen ' S
INFORMATION CERTIFIED B
Environmental Healih Specialisr er o es "°e
REPAIR: RE ALUATION:
Size of Septic Tank: allons Size of Pump Tank:
Nitrification Line: � � �S �' �
Depth of Stone: 12 inches
Ma�c Depth of Trenches:
Altemative SysteJ� : Conv. Pump LPP Pump M
Remazks: !�, � � � n �v�r � � � � i .��J
--�E�✓ `=_ �',�-�-�����-------
Date Well Approved: Well should be 100 f� from any sewer system
BY Environmental Health Specialist
Date Sewage System Approved: / Z��'� 4-
gy (�(� tiC� ,�9�c.c�..-.-� Environmental Health Specialist
CERTIFTCA� OF COMPLETION
Contractor d �'�=�'�-� �
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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 yeus 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 �
the site plans or intended use change this permit is subject to revocation. �
(G.S.130 A-335F) �
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I.ocation of sewage disposal sewage system sketched on back.
(OVER)
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
,�+ later date. Note location of water supplies on adjacent lots.
C�ll-� � S�) ��ivcnr�fl �% (2)
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Site Evaluation Application
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Fee Collected YES �
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1. Permit requested by:
Address: 1 /
Date: $'�3' 9 y
APPLICATTON FOR IPiPROVEMENTS PIItHIT
owner/prospective owner:
agent:
,r.Li �✓
Home Phone ��: � Business Phone
2. Name and address of currenx owner: ����Ci✓^�,
-� , �, S. rn�-, ,✓ �'-�., �- __ _ .
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3. Property Description: Lot size: �
4. Tax map ��: Township: �l� ✓ti �/
Subdivision Name: �o �!� �f�r�
5. Direc�ions to pro=rty: State Road �n� & R ad Names,/� etc.
. . O /. ) . �: �: ,• � l r, .,� � L� � � 7_ rr�X �
Lot �'�: 2—!�
� � ti' / �-I�S � �'
6. Permit requested for: New Installation: 1�� Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served: '7�
8. Dimensions of Proposed Structure: Width: Depth: 3�
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? t eS 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:
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12. Clearly stake a17. corners of the property and the corners of all proposed structures.i
I hereby make application to the Person County Health Department for a site
evaluation or existin� 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. - 5(F)
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S' gned wne or Auttiozi�n Agent
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Permit Issued
Permit Denied
Plat Observed
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i�ACTORS - SITE EVALUATION AREA 1 AREA 2 ARF.A 3 AREA 4
1. SLOPE (X)
2 . SGII. TEXTURE (i2-36 in. )
(Sandy, loamy, clayey,
Note 2:1 clay)
�? . SOIL STRUCTITRE (iz-36 �.
(Clayey soils)
4 . SOIL DEPTH (i.n. )
.5. RESTRICTIVE HORIZONS (in.)
(Iu�ervious Strata, rock)
6. SOIL DRAIi1AGE/GROUNDWATER
(bcternal � Internal)
7. SOIL PERMEABILZTY
(Percolation Rate)
$. OTHER (speci£y)
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9. SITE CLASSIFICATION
(See below)
SOZL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECO2�4fENDATIO NS / COMMIIITS :
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S:�:TE CLASSIFZCATZON �IAGRAH (Include: Soil areas, property lines, roads, streams, gullies,
Wet areas, fill areas. wells, water bodies, slope patterns, etc.)
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