A29 107-Aerson County Health Department
Sewage System Improvements Permit
Date: ��"-� ' Permit V id After 5 Years Pennit #
Owner: -- anJ e ;�`�'[� � � $}�# �
I.ocation/Directions: T— � •
Subdivision Name: � � � �� � � � t #
Lot Size: �of Dwelling•
Water Supply: �vate: �Publ�c.:.�rn,a--" u° om unity:
Bedrooms: Gazbage Disposal.�%
Basement ���asement Fixtures
INFORMA D B � ` .�
c....:....;..... 1)_ A it e�_ x er or �tative
REPAIR: — � ` REEVALUATION:
Size of Septic T���� gallons Size of�Tank: � ,!
Nitrification Line: 1% � � '
Depth of Stone: 12 inches r�' � �'' ,
Ma�c Depth of Trenches: - ` � `
Altemative System: Conv. Pump LPP Pump ��"'
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Remarks: r.�: s�.�-
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Date Well App :��Z Well should be 100 f� from any sewer system
BY san;tarian - - 2
Date S e ste roved: �
BY Sanitarian ,
�ERTIFT ATE OF COMPLETION ,..3
Contractor. ) j M �, n3 �` �
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ � — — — — �
"d
Sewage System location, installation, and protection must meet r state and local �
reguladons. Septic tank should be pumped out every 3 to 5 years and shall be maintaine�
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 q� i
'/";,;
the site plans ar intended use change this pemut is subject w revocation.
(G.S. 130 A-335F) ' ' ``�x �
�a y
Locarion of sewage disposal sewage system sketched on back. �
(OVER) �
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. �erson County Health Department �
Well Permit �
Date:_�This Permit Void ter 3 Years '�
Owner � ���
Location/Direcdons:
r� v► a t�t� i�yr
Subdivision Name: �� #
Drilling Contractor: 'd.�� c �,��.j�7
WELL CONSTRUCTION �
Distance from Nearest Propercy Line�,��s Distance from Source of
Pollution � �
Total Depth:� � F� Yield: 3 c2—GPM Static Water Level � Ft �
Water Bearing Zones: Depth % a—S� F� F� �,�'�t. �
Casing: Depth: From �_ to Ft Diame ✓� Inches
TYPE: Steel � Galvanized Steel
If Steel. d� owner approve: Yes No
WeighG �_ Thiclrness: eight Above Crround: � vI'nches
Drive Shce: Yes `� No
Were Problems Encountered in Setting the Casing? Yes No �---• �
If "yes" give reason: �
Grout: Type: Neat Sand/Cement Concrete
Annular Space Width 3 Inches
Water in Armular Space: Yes No v"
Method: Pumped Pressure Poured ��-
Depth: From _� to . � � Ft
Mat als Used: No. Bags Portland Cement _� Weight of 1 bag
�'Je'� lbs.
If mixture (sand gravel, cuttings) - Ratio: �._ to �_
ID Plates: Yes � No ►t�
4 x 4 slab Yes �— No �
LING �,
Devth . .�
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT.
_ � ,-�;
Si e o on Date
,:� � ` _� , "
12%30 9
�•"� =J-:€ anitarians Signature Date Issued
Sanitarians Signature Date Completed
Sketch well location on reverse side.
Site Evaluation Application
Fee Collected YES Y
pd �� 'U�
1 e�-�°l �
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Date : � - a `� •
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APPLICATT_OId FOR IMPROVEMENTS PERHIT
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1. Permit requested by: owner/prospective owner:
agent:
Address: p?��� �f�in ^
Home Phone ��: �j/d__S9`�-p�i
tsusiness rnone i�:
2. Name and address of current owner:
� }�'✓YI �-f�
3. Property Description: Lot size: ��6D �GrY�
4. Tax map ��: �� - � Township: Rd�(be r�
Subdivision Name: �//Q� Lot ��:
S. Directions to property: State Road �� & Road Names, etc.
�iU►- Ir�n�-luh. �d , l rnil-� �as�- Oq,�r'bl ���h'on � Ge
6. Permit requested for: New Installation: • Repair:
� ��C Q,� � Additional Renovation re-using present system:
7. Number of occupants or people to be served: �f�
8. Dimensions of Proposed Structure: Width: c�� Depth: o� �
9. What type (if any) additions, expansions, or replacement is anticipated to the struc-
ture or facility t at this sewage disposal system is intended to serve?
A��� oZ C/J-r l�a.r'.�GC� �a �2yC`�+�s�%RC�i ��'�-i �'�-�''��� y
10. Water supply private? "�/ public? _
Other source? (Specify):
Are there any wells on adjoining property?
11, Type of structure or facility
Type of dwelling: House: _
Type of business:
Number of bedrooms:
Basement? Yes No
community? spring?
If so, identify location:
Proposed: Existing:
Mobile Home: � Business:
Number of Employees: .
Garbage Disposal? Yes ro
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. 130A-335(F)
� .
Sign d Owner or Author'zen l,gent
Permit Issued
Permit Denied
Plat Observed
i�ACTORS - SITE EVALUATION AREA 1 AREA 2 ARF.A 3 ARF_A 4
1. SLOPE (X)
2. SGIL TEKTURE (i2-36 in.)
(Sandy, loamy, clayey,
Note 2:1 clay)
3 SOIL STRUCTCTRE (12-36 i.n.
(Glayey soils)
4- SOIL DEPTH (in.)
.5. RESTRICTIVE HORIZONS (in.
(Impervious Strata� rock)
. SOIL DRAINAGE/GROUNDWATER
(bcternal & Internal)
. SOIL PERMEABILITY
(Percolation Ratc)
g. OTHER (specify)
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9. SITE CLASSIFICATION
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R.ECO2�4SENDATIONS /COMMErITS:
S:�:TE CLASSIFICATZON DIAGRAH (Include: Soil areas, property lines. roads, streams, gullies,
Wet areas, fill areas� c�ells. water bodies, slope patterns, etc.)
.
� �A 005�2
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PERSON COUNTY HEALTH DEPA.RTMENT � '
WELL AND SEWAGE SITE, LOCATION IlvIPROVEMENT PERNIIT
Tax Map #/� d%' Parcel #% D'7
Zoning Township 12d�-a---�-
Owner/Contractor 7"pu�, �.p�� Date �. -� - 9 S
Location/Address 9 �.��--t%z lB�a .�c..p 112.�`' �� ,�-�t.�'�
Subdivision Name �"l
S.R.# �.�, • �f- y�c.
Lot# N/�
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i = � �y, ,�,�7�`
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SEWAGE SYSTEM
Lot Area $.1 yt v..�-e�
Mobile Home
# of Bedrooms 3
Ob � .�l�'
P`
TIONS
Size of Tank�l�;5 "� o-00
Size f Pump Tank /✓/�
rtn cati n Line Gc�o' lC 3�,�g��zg1�
Max Depth Trenches �;�,t.�!��
Pernut Void after 60 months. Permit Void if not in compliance with zoning regulations.
Pernuts may be voided if site is altered or intended use changed.
Well and Septic Layout by
Comments:
Date'd,- -� Installed by �Lv��c��. Approved by ttl..�:2,2 ,��c-�.�,L
WELL SYSTEM SPECIFICATIONS
Individual '►/' Semi-Public.
Public Replacement,
Site Approved
Well Head Approved
Grouting,Approved
Date
Air Vent \
Required Well Lo�
Well Tag
by
Tivs repoR is based in part on info�rnation provided the homeowner or his/her representative in the application submitted for this pennit The
environmental health specialist is not responsible for false or misleading infoRnation contained in the application The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in this repoR that may have resulted from false or misleading
statements provided to him in the application Neither Pe�son County nor the environmental health specialist wazrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�petnutsam O1/95 rev.1.0
ORIGINAL