A29 150�4-3�-1997 �9�41At9 FF,Of1 FEP,SOIJ Cf_bJPJTY HEALTH DEFA TO 5978827 P.n1
Receipt � � �0 7�,2 P�1 ��' �� .� .._ ~ Date ' .
� 37�0 ' �PPi ICATION F(��2 SE V C�S ���" �q�
�.. AS�� -�.x ,�.� � �.' "� '` z ���,��_�"�''��_
��� � ..,. �. �?�' �.*�i �_ p,"�, '� ��;�'� -w�� �eC•Hl.: eS � .�, �y �I.�i '��.. ��.� � . .: ,�f� ���'r,� .��m�.,''�r''��I I�'' " .
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Yl Imorovements �ermit(Fstablished/Re�'vrded I.ot) _ Reinspection of �xisting Syscem (T.,oan Closing)
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ImpFovements Perrnit (Unrecorded T.,ot)
Permit (Mobiie Home Reotace�
ts Permit (Addition)
}�acteria 1 Cllemical
J ��' Ike ✓S�.
l. perrr►�t� reques by:.
�wner/prospective o�,vned�gent: � ��
Address: ��1�� ���.--R��'
ome Phone #: `1 i0
usiness Phone ��: Q(� ���'CO
RepaidReplace existing
X 1'ermit for New Weli
^ �Zeplac� Existing Weil
� Pctraleutn I �esUcide
cic Systcm
7. D1lTlensions oC Yrok�oScd St[tilcttire:
W idth: Zg�
llepth• g�,
LC2�
8. `Vhat type (if any, additions, expansioes, or
replaceme_nt is anticipateci to the sttvcture o; facility
thac ttiis sewage disposal systettl is inteildz.d co serve?
Name a d addre5s of cucrent owner: 9. ��ater supply t}Qe:
�� `� �ktS �t� S.J.tTf private � . public ❑ commvnity ❑ spring ❑
� � Are any wells on adjoining property?Yes ❑ No [�
Tf so, identify location:
Property Descxigtion: Lot size:
Tax Map#: ' � �"2-q
�'arcel#: � '
Township:� 0�= ��- -'h �u-
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. FJirections ta property: State Road �& Road
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I0. Type of structure/faeility: Proposed: ��xisting: Q
Type af dweiling:
kiouse: G7 Mobile Home: C� Business: ❑
Type aP business:
Number of Employees:��.. .
Number of bedrooms: � �
Gat'bage Disposa]? Yes❑ No�
Basement? YesU No� Yf so, # of basement fixtures:
6 htumber of occupants or people to be served• 3—
� �CLEAR�'S,' S'�'AI� ALL CORNERS OI+' T� P�tOPERTY A,ND THE COit1�IERS OF A.LX,
PROPOSED STkZ.CJC�URES•
I hereby make ap�licatioq to the PBrSOri County Aealt�l D�paxtmerit fvr a site evaluation for ihe on-site
sewage disposal systettt for the a.bove deseribed propetty. i agree that ihe eontents of this application are i.cue
and r�present che maximum faeilities to be placed on the property. I undastand if the site is altered or the
intended use changes, the permit shail become invalid. I understand that before an Improvements Permit can bc:
issued, I must present a survey plat of the propecty to the Health T3ep� I understand that in the event I have ttot.
delivered a survey p1aE of the propeRy to the Hcalth Dept. wi�iin 60 DA.XS after the date of the evaluation of
ttte�site by the I�ealtlt Dcpt., this application shall becdme vo�ti and all fecs paid forfeited.
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� Sign Owner or Authorized Agenl
TOTAL P. �11
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� B 1802
�'ERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE; LOCATION IMPROVEMENT PERNIIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # A � � Parcel #_
7nnino TOwIlSlllp
Owner/Contractor_
Location/Address _
Subdivision Name
/ ���� Date - U - � Sic�
�` ' '�t� /%S�J
,- .
�..L�F' o h S.R.# / �
Lot#
SEWAGE SYSTEM SPECIFICATIONS
E�epair Lot Area��o �tc✓t5 Size of Tank %�(�� Gl�� ��s
S� - Mobile Home �_ Size of Pump Tank r� �✓�
Business # ofBedrooms�_ Nitrification Line ���Q �X.3 �
Max Depth Trenches .2 !� "
Permits may be voided if site is altered
Well and Septic Layout by.
Comments:
use chan�ed.
Date �/- I�- Installed by T ��-��' Approved by /�l�' �D �,w�,...
_.__.�z—,►� ,nol � 7 . ° 11--S1-`f "(
ell Permit Paid
SYSTEM SPECIFICATIONS
[ndividual�_Semi-Public Required Slab 1/
Public Replacement Air Vent �
Site A�proved Required Well Log
Well Head Approved �� ,�� Well Tag
IGrouting Approved D- -
This report is based in part on information provided the homeowne'r or his/her
representative in the application submitted for this permi� The environmental
health specialist is not responsible for false or misleading information
contained in 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 future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
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AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: �%D— cj r% IlViPROVEMENT PERMIT #: Z
TAX MAP #: � 9 PARCEL #: ��D
OWNER/OWNER'S REPRESENTATIVE: te Y.l"� C����f�
LOCATION/ADDRESS:
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2 a�" �,Cn r�. .�0 1 uG� �.-e �/�
SUBDIVISION NAME:
SECTION OR BLOCK:
AUTHORIZATION FOR CONSTRUCTIOI�,ISSUED BY:
AUTHORIZATION CONDITIONS
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LOT #:
1. The Wastewater system construction and instaIlation must meet all of the conditions of the
attached site plan and specifrcations as set forth in Improvements Permit #�31�Q� The
constn,iction and installation must also meet alI applicable rules and laws.
2. No portion of the Wastewater system shall be covered or pIaced into use until inspected and
approved by the Person County Health Department.
3. Any alterations in site or soil conditions (including structure Iocations) 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:
l 15�JllL-97 TUE 11:08 AM EEH RORBORO 15
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FAX N0. 19105973171
IF
P, 02/02
CtiARLES R. S
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PERSON COUNTY EHVIRONHENTAL HEALTH '' . :
• • iiELL LOG � ' ,.
Owner.
Sub�ivision Name:
Drilling Contractor:
SR# ' � �
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T .� • Jl
Distancc from Nc.arest Properry Linc_ /o Distancc Srom Souxcc af
1'o]lutioi� /aD '
`I'otal DcI�lh:_,._L�.o__-- I�t. Yield:�.. _ G�'M Static `��:tc. l..cvc]--o?o �'�.
Watcr Bcaring "7_oncs: Depth __�Ft. ��rs Ft. /SG Pc.______u Pt.
Casing: Uepth: �rom_Q,_to��Ft. Diametet:__�___vlches
"I'YPE: Steel � Galvanized Steel
If Steel, does owner approve: Yes No
� Weight: Thic.lcness: l�k Height Above Ground: l�I Inches
Drive Shoe: Yes ✓ No
Were Problems Encountered in Setting the Casing? Yes No ✓
IE "ycs" give r�ason:
Grout: Type: Neat Sand/Cement � Concrete
Annular Space Width Inches
Water in A�nnular Space: Yes No
_ . Method: Pumped �Pressure � Poured ✓ � � - - • •. � - �
Depth: From D to �. � Fc. . .
Materials Used: No. Bags Poztland Cement Weig�t of 1 bag_Ibs.
Tf mixtuire (sand, gravel; cuttings) - Ratio: to
�ID Plates: Yes ✓ No � ' � � � .
� 4 x 4 slab Yes�No
I HEREBY CERTIFY THAT THE ABOYE INFORM r�TION IS CORRECT AND THAT
THIS WELL WAS CONS'fRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY•THE PERSON COUi�'I'Y HEALTH DEPARTMENT.
� � �gnaturc of Con�ractor D���
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