A29 149.. � �lD�� � �-�.� � �z�
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APPLI ATI F ERVI
. I �
� . .. �W`� 3 ` i Kit L <.h �i ¢/�..
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` �. z �� t'3 � X "4.. 't � < F. . i,. ES n -,7 � .. Serp�ICW ��Y a ,..... , . � v r :,..;> < .; ,�.. . :. . -�., .e , . . :�.�"•.
K�°` ..x..;.�.! . .: �8 .'..�..ci af >`.KA'... . ..?. ... .........<a ).
Improvements Permit. (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing)
Impxovements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
Permit for New Well
_ Replace Exis[ing Well
. Permit requested by: .'�-�,. %''��` 7. Dimensions or Pro osed Structur,e:
owner/prospective owner/agent: Width: � '���.y- �
. . . ` � T�enth: _ ,.� ?3
�
ome Phone #:y
usiness Phone #:
v
��s 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?
, . j (� ��
Name and addre&s of current owner:
�"c� 4� �v �d.: ,� ►.� � � o� S u�i '
. Lot size:
Tax Map#: .�. � �
Parcel#: � \1'
Tnwnshin� � � �.\t�_ �-�
. Directions to property: State Road #& Road
iames;�tc.
��v��r Ct21 �a- RoSeV�l�� Gro'
e �r- o � � h ec
9. Water s y type:
private . public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No Q.
,ff so, identify location:
�- es�A- s�ore o,� ��2�
5. Number of occupants or people to be served: � _
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pet'sOn COunty Health Department 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 I�°ept. I understand that in the event I have not
delivered a survey plat of the property to the Health Dept. withi 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void nd all fe p �d forfeited.
� �.
/�
. Type of structure/facility: Propose�Existing: Q I
Type of dwelling: ,�
House: 0 Mobile Home:�l Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: 3
Garbage Disposal? Yes ❑ o �
�Basement? Yes ❑ No�' f so, # of basement fixtures:
d
z Signc wner or Authorized Agent
C p Qt�f�e�l�
/� O�-01� � O M'e. 1 IJ �% �'' i. V� W o0..Y —
Permit Issued LY
Permit Denied ❑
Plat Observed C7]�
��
Signature
Date � 7 ~ �� . �
.� , � • , !
Y
s�oeec%Y
son �x�vr� u:•ss ►xa
WDY. LOAMY. CI.AYEY. NO7E 2:1 CLA1�
SOfI. S77tUCTUAE (12-36 IN.1
u�v sons�
SOIL DEPT}1(IN.)
RESTRICTIVEHORIZONS(INJ '
iPERViOVS STRATA. ROCIq
SOIL DRAINAGFJGROUNDWA'IER
�x�t, a� QrrExx�ca
son e��t�+�snm
ERCOLOATION RATEi
AVAILAB[E SPACE
SRE CLASSIFICA170N(SEE BELOW)
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SSUITAULE PS�PROVLSIONALLYSU[TABLE U•UNSUI[ABLE
RECOMMENDATIONS/COMMENTS:
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SITE CLASSIFICATION DIAGRAM (Include: Soil areas, propercy lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.) C:VIMIPRfl�DOCS�APPSEC.SMFWANCEPC
. ,.
B 1416
PERSON COUI�YTY HEALTH DEPARTMEN'T
. ,_._ . WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Retocation Activity shail be issued until Ae�thorization for waste water system construction
6as been issued.
Tax Map # � ..�� Parcel #_
Zoning Township
Ovmer/Contractor G Ye G - a r�n c
Location/Address l-}-q _S'-� �kG, �c
�
Date q - � - �'i �
S.R.#
Subdivision Name Lot#�� J l b2
Permits may be voided if site is altered
Well and Septic Layout by �
Comments:
Date
ell Permit Paid
Installed by
Approved_j�
Head Approved.
rting Approved_
Comments:
Date
use
Approved by
WELL SYSTEM SPECIFICATIONS
Semi-Public Required Slab
j�placement Air Vent
Required Well Log
� ,� Well Tag
Installed by,
Approved by,
This 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 in%rmation
contained i� the application. The environmen�al 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 futur or that the water suppiy will remain potable.
c:\amipro\permit.sam O1/9��ev.1.1
�
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
' (Void sixty (60) months from date of issuance)
DATE: � 3 ` IlVIPROVEMENT PERMIT #: � �
TAX MAP #: PARCEL #: � %
OWNER/OWNER'S REPRESENTATIVE: e
LOCATION/ADDRESS:
��`l � o� � �t�T Uvt G� ✓he►� a� S�� � 1�%
� 5�.� 1( b -z
SUBDIVISION NAME:
SECTION OR BLOCK:
LOT #:
AUTHORIZATION FOR CONSTRUCTION ISSUED BY:
AUTHORIZATION CONDITIONS
1. The Wastewater system construction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Permit #/' / T r�r. The
�--r----
construction and installation must also meet all applicable rules and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any alterations in site or soil conditions (including structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authorization and associated permits.
4. Conditions:
Person Requesting:
i��
,CONTROL 40.00' IS • �
CORNE�t CM
. , I I , S86'36'23"E
401.68' TOTAL
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I N •M- I I � •� •
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NS 40.00' � �/I
Nq�.
0.7I I IS S86'36'23°E �v�
I400.03' TOTAL
a'�-' � �
N�°'o� � 1
� � ; o� � 4
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. 10 � � �
W Z� � 1. 00 AC .
� I I
NS I
\ I IO'00' IS S86'36'23"E
I 398•45' TOTAL
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WI 4 �I
0.00
NS I iis S86'36'23"E
305.25' TOTAL LOT 2
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IS
S86'36'23"E
91.61'
�
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�� IS 30.92'
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rs
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1 . 04 AC .
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IS
IS
IS
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• , r �ri;i.i. i.oc
rD�1[e'� � ��_-�i'
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Own�i�:.��� _ ���m �- YG r
Location/Dixe�io�is: _._.�f S 5�.�.-�ti ��y-�S .__....---- SR�� JI �4
. . - ----- --.. _ _..-
• � �:.L:':visio>> N�uri�;: -----..---- •
. . ..._.__.
. LU1 �� ��
rillin� Conuacti�r: �" _ _ . _....___.__—
� L �1.�/1_ 1_._.�i.�L...�/ -� �'--+-/�1� r.
Wr(..[_��(>N�CrIC}N
• � Dista��cc from Ncr�r�:s� ]'r�,�,: � i�� I_,;���•.__.._L�_�! �s llista��cu .froni Source of
Pollution o � ��� .
, Total Depth: � `�— ��t_ 'i i�lcl: � > �
----�d _.___ �,� M S catic Water Lcvel F[.
Wa[cr Bearing Iones: Dcl>t �� _--g''a—. _ 1:[. 9'3 1;�
Casing: IJcpth: From rJ - . _Ft. �'t. :
. TYP.�: S�ccl —_ D_-_to.__ ,`�----�'�- I.�i.unc�cr: �� .rnches
_ Ga1v:�nizc.cl,St�l .�
�If Stcel, docs o,�vilcr :i����rc>v�: Yc;; `� .
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� � "1',iick�-ics:,:_ ..1 �'1=Ic��;ht Ab�vc Grouncl:=� Znches
]�rivc Shoc: Xcs v'"-N�, •
Wcrc l'roblcros Er►�.:ountcrcc( iu ,�cttii��; llic C;risin ... '�
f�'' Xcs__________ No (
� -�� ��ycs' �;ivc rc.isa:: .
. Grout: Typc: �t -------- _------ _ —_ __
Nc� �:i�ul/C�'►nw,t .�-. :
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A.nnular.Spacc_Wic,tl� " � ' ' ' '
{ 3 Inchcs
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--�-- ------ _
�itcr in Aluiul�u-.�l�:�c�:: �'c::-- ..--- No �_--
Mct�lod: Pum�c;d , . .,. _ ---- _______�
--. .--._.._ _._---- I� I c...,., u ��; __ l�c� t� r�:cl ..
v��cn: r-r�n, � c t <<� _- --- � .
Matcrials Usccl: - ---%� � c:•t. � , .
N��. .13.1�;s l'ortl:ul�l Ccmcnt
Zf mixcure s. ,, `� Wcight of .1 ba lbs.
( Znd, �I IVC;I, c:u[tir��,::) - Rtttio: �- to 1 �
�ZD 1'lates: Ycs �-� No ----- .
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De th ------- -----------_ _ �
F��'m � T= -. _�__ -- . ` rorrna[ion Dcsc�-i tion �
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Z�EREBY CERTZF�' T�-IA`I' •(�(_IE �.�1.30V1� 1NFORM�1'1'1ON IS CORR ���
'RYti
�� T�S WELL WAS CONSTItUC'1'L1� 1N AC;Cp�Zp�,NC,� y�,�TI-� REGULr�DTHAT�� t�x�.�
ATIONS ' c' '�"
�ORTH BY•TkIE PERSON C�7UN'I'`r l II=�I.TI-I I)I�P � SET�:', �,f� .
ti. . - . AlZ"1'MENT. ; :��<:>
,.,.
ri;�
: � .. _ . ��r:��r- c�c%.l� 3 �
, �
. • Si�;naturc �f c"'ontr,�ct��r �--�--.. �j,
. Datc ,f �,�,:
PERSON COUNTY HEALTI3 DEPA�tTMENT
3�SA SOUTH NIADISON BLVD.
RO:YBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant ,��' �� e/ �c (�``e�
Address 232q %/�ee �es�r� �, County ��sSo.�
Collected By �� / e/'��/
Date Collected 3 Z v Time Collected ��� ��
Source: L�J'Well ❑ Spring � Other
Location: �d"House Tap
ONo Charge arge
pWell Tap O Other ���rz ��;� k
**�*****�***�********,�**��*�*��****�***�**�'**�*�*�*�**�*�***��********��**�***
****�***��********�*****�******�****�***�*******�*�************�********�**�**
Total Coliform
FecaVE. Coli
�T esults
Present Abse,nt
� ��
o �d
Reported Y M L� � 7 �
bactreport