A29 11� �, z
._. � . ��
� i r -e vc�, -�-- � �
Person Coun� Health De artment "
Y p
S�e System Improvements Permit
Date• T�h' Permit Void ter 3 Years
Owner: -.�.] G m���l/'c�+�};�, SR#
Locaaon/Directions:
1j! �h�
Subdivision Name: Lot #
Lot Size: Type of Dwelling:
Water Supply: Private• _ y,.r� Public: � (�
Semi Private: If not Private Tax Map# Q
Parcel # of Water Supply or Name of 3
Supplier# c�
Bedrooms: Garbage Disposal
Basement Basement Fixtures
INFORMATIpP CE,R D BY
SaI11I8I]SI1: � '� � 14 r ������'"'� owner or iepresa�tative
�P•�: REEVALUATION: �
t�- —j' ^ �
Size of Septic ank: � �� allons �'�'( � '� c2d — — — ;,
-- '�� � g , � , / � ( �
Nitri�cation Line: � n � a��� 3, 2c7 x
Depth of SWne: 12 inches
Max Depth of Trenches:
OPERATIONAL PERMTT: yes no
Remarks:
-------------------------
Date Well Approved: Well should be 100 ft, from any sewer system
Bl' Sanitarian
Date S� ge ste A ved: —
BY anitarian �
TIFI TE OF�OMPLETION �
Contractor. ����-. � � f c �
------ -------------- �
Sewage System location, installation. and protection must meet state and local �
regulations. Sepdc tank should be pumped out every 3 to 5 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 COunty Health Department before any portion of the installation is
covered and put into use.
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
i �� °2 l , °� �
�� ���
. �e �Q.�-1'�-
�
U
�
a
z
Improvements Permit (EstablishedlRecorded Lot) I_ Reinspection of Existing System (Loan Closing)
Improvements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Permit (Addition)
ace existing Septic System
Permit for New Well
_ Replace Existing Well
l. Permit requested by: . Dimensions or Proposed Structure:
owner/prospective owner/agent: ��e s� Ye �1 idth: 1� F v�Yn� S�, e d� -
ddress: Q u � c� . Depth: o2U w o Y k s-�a �
o b o 0 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 #: ,S� °I `1-7 I g �
usiness Phone #:
2. Name and address of current owner: 9. Wate�r s�u , ply type:
Sct M private L( public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No ❑
If so, identify location:
3. Property Description: Lot size: a�� � C�
. Tax Map#: /J ��. 10. Type of structure/facility: Proposed: DExisting: ❑
Parcel#: 1 I Type of dwelling:
Township: FoY'� House: ❑ Mobile Home: ❑ Business: ❑
5. Directions to property: State Road #& Road Type of business:
ames, etc. Number of Employees:
-S —� o � Jv� � b e o v� c� Number of bedrooms:
�,,, �a�-�- a � S o-� � s-L- - � Garbage Disposal? Yes ❑ No ❑
o� �� N o o.1ti C�a�� asement? Yes ❑ No ❑ If so, # of basement fixtures:
6. Number of occupants or people to be served:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY ANll '1�tiL I;UKiV�KJ Ur� ALL
PROPOSED STRUCTURES.
I hereby make application to the Person Courity Health Departmerit for a site 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. 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 shall become void and all fees paid forfeited.
Signed Owner or Authorized Agent
Permit Issued ❑ Signature
Permit Denied ❑
Plat Observed ❑
Date
" FACTORS-STTEEYAi.VAT10N AREr+,l ; AREA2 ARE143 AREA# ::
_ ___ . _. .
1. SLOPE (%) S S S S -
PS PS PS PS
U U U U
2. SOIl. 7"EXTURE (12-36 iN.) S S S S
(SANDY, LOAMY, CLAYEY, NOTE 2:I CLAn . PS PS PS PS
U U U U
3. SO[L. SiRUCTURE (12-361N.) S S S S
(CLAYEY SOILS) PS PS PS PS
U U U U
4. SOIL DEPlN (IN.) S S S S
PS PS PS PS
U U U U
3. RESTRIC77VEHORlZONS(IN.) S S S S
(A1PERVIOUS S7RATA. ROCK) PS PS PS PS
U U U U
6. SOIL DRAINAG&GRODNDWATER S S S S
(EXTERNAL & INTERNAL) PS PS PS PS
U U U U
7. SOII. PERA7EABiL1'fY S S S S
(PERCOLOATION RA7E) PS PS PS PS
U U U U
8. AVAI[.ABLE SPACE . S S S S
PS PS PS PS
U U U U
9. SI7ECLASSIF[CA770N(SEEHELOW)
SOIL SERIES
S-SUI7ABLE PS-PROVISIONALLY SUITADLE U-UNSUITABLE
RECOMMENDATIONS/COMMENTS:
STTE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.) C:�AMIPRO�DOCSIAPPSEC.SMFINANCE.PC
�
` 0763
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # I3 2 9 Parcel #/�
Zoning Township ,G%r,��� ���-
Owner/Contractor �r/� Date /o-�- 9 S
Location/Address � y rGz�*-�� � .� ��-�-�..z �-., -�� --�a��
` ) S.R.# �'
As Installed
�
, �
, � ' � ���i�G <'�r ,
�� , ���
` � is�� ,
'Subdivision Name Lot#
�
�
� � . i �
r �
, :. �
' ,71, ,
—/�'`
� �� �
SEWAGE SYSTEM SPECIFICATIONS
epair Lot Area �l'"����-
FD t/' Mobile Home
usiness # of Bedrooms„�._
Size of Tank I 8-�-�'
Size of Pump Tank
Nitrification Line��3f..•
Max Depth Trenches
Permit Void'after 60 months. Permit Void if not in compliance with zoning regulations.
Permits ma be voided if sit�' is altered or intend d use chan ed.
Well and Septic Layout by!��•�r �� � l�c/..r�-G� ���-�-„--
� Comments:
Date�v-�� �� Installed by �� Approved by Gc%� �r-r�...
� .� � , e v
Well :
ell
C'
Instal
by
SYSTEM SPEC FICATIONS
Re uired Slab _
t A'r Vent _
ell Tag
Well Log
by
1'his report is based in part on information 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 pmperty or for statements in this repoR 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 OU95 rev.1.0
Appiicatccn �ai�: lb a��
Amoun4 Paid:
���aipt �:
� �-� �� .� , �
, _.__ _ _ � I�I��.� ��
- - _ ������
� �a�-n.a-o�a�-M� <o���mll 7�3���.11�1�-_a
�+PP�ICATIOid �OR SEiiVIC`S
a ax i�1an T• /"� � I
�arc2� � � (
��
�e�' � � �
� �a�o
� Q l%
iF i'1-IE INF2�RElfl�4T1OM 8� T�9E A►P�L9C,�TiOR! ��Ft ,�PI 16l�PF��Q/Ei�iENT P��II�iI�' IS IiNCORRE��. F.ALSiF3Ei3,
Ci�Ai�G�� t�R THE SiTE !S �'►i.TEiiED Ti�EiL! 'TF�]E Ii�fiPF�01�lE�iE�i ��9if�ilT AND ,�l9TH�R6�T1�N it3
Ct3NSTRUCT SFIAL�. �3E�O�tiE IAIV/�LlD. . .
�'�) Pe�6t reqaa�ssted 4��: (�vun�r/agen�lpr�spective owner): I� � Dr'1� � vJ �U ►v('�N'v
Home Phone: �'z 503 �ZgU Address: �-!�1 �2 ;� o� �
Business Phone: 5�t'7 -3(c� 2 uXbo�'u= NC Z 5� 3
,�) Narvo� and as9dr�ss of caarrent owrnee: �wvv.� . l,� -' nl ���Cc.�St ��
44�rt �G„nL� ,,, o
: ,�k. v►�u J�IC 2�5� 3
3) P�op�rty De�cstiq�icon: �ot size: �•y9 �c
Directions to the properiy (!ncluding road
2 N� hOJSI'
4) 6�PO�OS� L1S0 �P9C� SQTl9L'$l8P2 �eSCTIpt➢OPl: answer each of the following questions:
a) Proposed _, Existing x, Type af Structure: Width: Depth:
b) Number of Bedrooms: � Number of occupants or people to be senred: s
c) Basement Yes X, iVo Will there be plumbing in the basemerrt? c,-S
d) �arbage Disposai: Yes No � �
5) !f�lat�r S�appiy ��pe: Private �, (new _ or existing�, PubiicJ Community� , Spring _
Are any welis on adjoining property? Yes_ No _ if yes, please indicate approximate location on the
.siie pian. I�� � S���h a J' �2.�,,Siv�n,C�
��'•
�) �oes �oaar pro�ee#y can#acn pcevioa�sly ae8e�atof�ee� Ju�as�i�tional w�i6ands? V�_ R�o �
F'�.�ASIE 4NO'P� TF9E ��LLOaAIING:
� s� PL�►T OF Ti�E �la0P�3aZ1( OR SiTE PL�1� il�llST BE �UB�lIT�T�� WITH Tl-flBS A���9C�►T9�i�.
9�6@OP�3�T'�( L9it�ES �A1D COF2NE�'t� 11AUS"!' �BE CL�diFtLV NiA��D. � ,
9'�!E PROPOS�� LOC.a►TiO(d OF �4Li. ST�ZUC'�UIZES fiflUST SE ST.4t�D OFz �LAGGE�.
9 T9-IE SaT1E MUST �E �DILY e�C��SSI�L� �'t3�t Ai� EV�►LUA�i�N B'l i�iE 9��L"fE�% �3E���T�liE�T
SiAFF.
I hereby make appiication to the Person County Health Department for a site evaluation for the on-site s�nrage disposal
system for the above-describ�d properfy. I agre� that th� cantents of this application are true and rzpresent the ma;cimum
faciiities to be placed on the property. I understand if the site is altered or the intended use changes, the permii shall
b�come invaiid.
��� �a D ..
Owner or L�al Representative
l�
\
,� /Z�I�
Da�e
PCHD, rev. 06127/02
�-��'?, �� 1� ��� ��
. `'' _'— � � ��� �
IE��a-���..a���.]L R33L�.�.Il�1�.
SITE PLAN
Name �. 1 J�V 1 C� �I a.t1�Cl Y1 Tax Map #/��' / Patcel #�/
�dtvision �_ Secrion/Lot#
�1. , ,', �P �./.1.2
Authorized State Agent Date
Systew camponeats represent appmximare conmurs only. The cnntracmrmustllag rhe sysrem pdar to begraning rhe installatioa to
insure rhatprvpergrade is maintained
" �r1�0.�+(� Q\� S�JQCi�S
- '��� `� C3�0(� c% , t�c� ex �s-� � �,��c� t�e��
s��: t� � �-,�
rcxn, f�. o�/�z/oi
�:��::" �::.:��.'.� ":-`.> .� . �.
:\`� ... � �� � :�:�:.
.. .� ..:: �: �� . �:�����..��:�:: �: ..` .
�. �... .���
,.:�.:.�:r :::�:..:.. ....:..:
... ....
::�; ��:��� �� .
_ . .�:'��� .
.. ..... ..: :::..:::: ..:..�. ::.:::..;.:...:.:::.... . .
. ... ...:..::..: ... :.:....:.. .
. ... :.:.. . .:.: ...::.
... . .. .:. : . :.. ...
...
1�.�n:�v:nr�nza�*-^����,q�.,1,3�:�:ffis �.:>�. 7�
�. : ��.a�•atii..11':�� �:
�'i'IlJ�9� JC:I�gt17JLH� .
Y.5���� S�� t3 S 1 L"]�� � n, ta � i A� i.YIlO Yl' 3'�L.�� �1l 8:(� a'tw �Y.Y LLJ S
Tax Map �� parcel #__1 j___ Township:
Applicant: A.��(i���i C� �I aVlnn,i'�
Subdivision. Lot # �
Location: _. �I U 1� a�r 1' v1c���
�
�yp� �g��$��' ��ap��y: ✓ Individual_
�e�a�irements:
�Q`� �d Site ApprovedBy: �� J�-$�-�
2 Grauti.ngApprovedBy:(v$� f(-fcS�os
Well Log: �s � 1f-/n-e5
Pump Tag: �
Well Tag: �
tlir Vent: � �
� Hose Bib: �
Casing Height: �
Concrete Slab: � �
Community Public
a�. � ,�,.�,
Liner:
�Installed by:
Depth set: _
Grouted•
I�ate;
Wate� �ample:
Well Dri11er• �—} t�p5�cu W��C, �,� LZ�,
Well Approved by:
��**See Att�ched Site 5��teh*�**
Wells must be 10 feet from property lines. ���
'�Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
Date:.
�,� � i' ���5 �S
� d�'r 1►—to—�73'
PCHD rev O1127144
i
��""��. ; + �� � �� ��
Y ' .." V ' � �ii �
I -�'�az..aa-sa�raaaz���rn. IE-3LQaeaIl�3a
pr�ll���� (�D ::
�. J .
Ce)i1�E).�i�,, tV!.lii�1' /l. � . .w /�'
D,t�� o��:;��:�i ,� �
Well Log
Owi�er: � t�'i � f_ n�l� Tax MaP �
Location: 44� ( L�u.r L �r,�. -�.�, �2 �
Subdivi�ion: I.at #
Well Coaatnection
��ace From nearest Proptrty Line (Minimum 10 fcei) `�4� .`
Distance from �egtic System (Minimum 60 feet) � d
Total Depth: ��,� Yield: ,,3 _____ GPM Static ater Levei: ft
Water Bearing Zones: Depth � ft #i ft ft
-�-
C�aslag: fp 3
I��pth: From �- �_ to f�_�____ ft. Diameter: (p �� in
Type: Galvanized Steel
Weigh� �� Thiclafess:1�» ._ Height above Cmound: 1�j in
Drive Shoe: Yes No Any problerns cncountered while seaiug c:asing? Yes No
I f "yes" give reason:
Grout: �
N�at: Sand/Cement Concrete GraveUCement
Annular Space Width _ inches Water ia Annular Space Yes _ No
Method of Grout: Pumped Pressure Poured Dcpth to Ft.
'_�Iaterixla GTsed:
No. Hags Portland cement Weight of 1 Bag �` Pound�
If auxture (sand, gravel, cuttings) - Ratio to
ID plates: � Yes _ No 4 x 4 slab _ Ye.s � No
Drllling Log Locs�tion Drawing
From To Formaiion
�
� , � >
�� � -.
£ /�
�_t-�g D � �J + �
i-----,
____�
I hereby certify that the above infarmatian is correct and that this well was constructed in accordance wzth regulations
set forth by +he Pzrson County Health Departmen�
Signature uf C'untractor � j� ( p �Q/1.�G�- ID # c� Q�a Date �(� .�-_J Q-[� �
�i �r �� fCV l)1�16,��i,