A29 158_ .il•, ,
Site Evaluation Application
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APPLICATION FOR
1. Permit requested by: owner/prospective owner: C/
� agent:
Address: �J� � ,
Home Phone ��: Business Phone 4r:
2. Name and address of current owner: /(//�
3. Property Description: L�t size:
Date: ��" a ' � �
4. Tax map 4�: Township : (� �G i�`�!1 i��
Subdivision Name: j ,g �L" Lot ��:
S. Directions to property: State Road �� & Road N mes etc
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6. Permit requested for: New Installation: _� Repair:
, Additional Renovation re-using present system:
7. Number of occupants or people to be served:
8. Dimensions of Proposed Structure: Width:
Depth:
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.
11,
Water supply private? � public? _
Other source? (Specify):
Are there any wells on adjoining property?
community? spring? �
If so, identify location:
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:
i
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 m�ximum 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)
,
Si d Owner or Authorizen Agent
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Permit Issued
Permit Denied
Plat Observed
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- SITE EVALUATION
1. SLOPE (X)
2. SOIL TEXTURE (12-36 in.)
(Sandy, Ioamy, clayey,
Note 2:1 clay)
3.. SOIL STRUCT[JRE (12-36 in.
(Clayey soils)
4. SOIL DEPTfl (in.)
5. RESTRICTIVE HORIZONS (in.)
(Impervious Strata, rock)
6. SOIL DRAI2IAGE/GROUNDWATER
(bcternal & Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
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AREA 2
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AREA 4
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9. SITE CLASSIFICATION ^�
(See below) �J
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable _
RECOMMEEt1DATI0NS / COI�fErITS :
S'�TE CLASSIFICATZON DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies,
c�et areas, fill areas, Wells, water bodies, slope patterns, etc.)
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�A 0021
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION Il1�'ROVEMENT PERMIT
Tax Map # � a,'�j Parcel # l� 8
Zoning Township ; � '
Owner/Contractor Mu � � S n l,� + I S o n Date a'� .S'
Location/Address Co rnpr o-F �,R.__ Il f� a a--r.� S,R � I 1(o�i�
s.R.# f��a �-t��y
Subdivision Name i I �� V e n Lot# lD
SEWAGE SYSTEM SPECIFICATIONS
Repair L�t Area 1� 3D f��� Size of Tank /D00
SFD tl Mobile Home Size of Pump Tank /�
Business # of Bedrooms 3 Nitrification Line �/DD � jC 3�
Max Depth Trenches aSS
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if s
Well and Septic Layout by
Comments:
Date� 7 Installed by_��i� CDx Approved by.
WELL SYSTEM SPECIFICATIONS
Individual ✓ Semi-Public Required Slab
Public Replacement Air Vent !/r
Site Approved ✓' Required Well Lo�
Well Head Approved Well Tag _
Grouting Approved
Comments:
environmental health specialist is not responsible for false or misleading infonnation contained in the application The environmental health spec�alist
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 Person County nor the environmental health specialist wazrants that the septic tank system will
continue to function satisfactorily in the future or lhat the water supply will remain potabte. c:�amipro�pemutsam 01/95 rev.1.0
ORIGINAL
PRRSc1N �(111NTY FNuq'RONMFNTAi. {�FAT,TH
WELL LOG
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Date: _ �� � (LSC� � S72# � ►
Owner: v � � .
Location/Directions: � �
Subdivision �Name: Lot #
Drilling Contractor: �
WELL CONSTRUC'I'ION - .
Distance firom Nearest Property Line Distance from Source of
Pollution � � .
Total D.ep.th: ��- Ft. Yicld: 6 GPM Static Water Level Ft.
Water Bearing Zones: D:epth Fi. F� � F� �t.
Casing: Depth: � From Q .t� o�� Diameter: Inches
TYPE: Steel - Galvanized Steel ES
If Steel, does owner approve: Yes No ��
� Wcight: � Thickness: .• � Height;Above Ground: Inches
. :
Drive Shoe: Yes No . i
. Were Problems Encountered in Setting the Casing? Yes � No
. If "yes" give reason:
Grout: Type: Neat Sand/�ement � Concrete ,'
. Annular. Space Width � 2 Inches �
P. ° .
Water in Annular Space: Yes No ;� �
� Method: Pumped � Pressure Poured �i ES
Depth: From � to � F� �
Materials Used: No. Bags Portland Cement Weigiit of .l bag__.lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
�ID Plates: Yes ✓ � No � � �� .
� 4 x 4 slab . Yes ✓ No
�
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. � ._
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Signature of Concr tor Date
A�pttcatton Date; �b .3D � O �
Amnunt �aid: � �
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APQlJCATiON Ft3R SEitVIC�S •
IF T'HE INFaRMATi�N IN THE A�PPUCATION FaR AN IMPROyE�VAENT PERMrI' iS� INCORRE�:7'. F�4LS1FiE��
C�}ANGED, aR THE SITE 15 AL'TERED. THEAI 'iHE IMPROVEiNENT PERMIT AND AUTHORIZA►T1�P170 .
CON9TRUCT SHALL BEC018E INVALlD. '� �O
1) Pemtitrequestedby: (Ormeriagendprospe�ve \� G• ��
Hame Phone: �� Address: ��D D E ti ,
6usiness Phone• �
n �
2) Name and �dress of cwrent awner; u� 1 SD
� lv � �I I . .
. C � _
3) Ptnperty De�siption: !�t size: ��� R('_ Townshlp: Subciivision: ► t�(��� Lot #�v �
D�ons to the property (lnduding raacf names-and numbers): •• .
E��GNi
4) Propoaed Use and Structure escription: answer� af the following questioas:
aj Proposed . Existing �Type af Structure: t#OL(SF, � Width: � De�th:
b) Numhec of Bedrooms: Number of occupants or people to be�setved: �_ -
c) 8asement Yes . No WWt�ere be plumbing in the•basement?
d) 6arbage Dispasal: Yss � . IVo V
� w�' �PPhF �: Privabe � (new _ ar exlstin� c/ }. Publ'�c � . ComfnwtitY'_, S�in9 � -
Are arry wells an adjoining proPerty? Yes No _ If yes, please indtcate apptmdmate loc�tori an the
.siie plan. •
6j Does your ptmperty cantain�revlousiy idecrtfiied �urisdictional w�lat�ds� Yes No `�
Pl.EA3E NOTE THE FOLLOWING:
? A Pl.AT OF THE PRflPEiZTY OR SITE PLAN MUST BE SUBMITTE� Wt17� TH1S APP�ICATION.
➢ PROP�tTY UNES AiVD CORNERS MUST 8E CtFARLY AiIARKED. •,
9 THE PROP03ED L�C�4TION OF A►Li. 3TRUCTURES MUST BE 3TAi(� OR FiAGGE£�.
A THE SITE dAU3T BE RE�4DILY ACCESSIBLE FOR AN EVALUATION BY THE �IEA►L'iH DEPARTMEiNT
STAFF. �
I hereby maice applic�tion to the Person Caunty Health Department fnr a siie evaluation fw the on-siie sewage disposal
system for the abav�described prope�ty. 1 agres that the corrtents of this appiicatton are tcue and re�reserrt the m�cimum
�aciiiites to be placad an the property. 1 understand ifi ti�e siie is aite�ed or the irrter�ded use clZanges, the permi� shall
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cwner or L.er�ai Repres�nta�ve
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WELL PE�tMIT
PI.EI�SE SEE A'TTACHEI) PY.AN FOR WELL SITE LAYOU�'
Tax Map #: Aa9 Parcel # 15 $ Townshig � 1 �U � � 1 \ / �ns1�. . 1-a�1�
Applicant ��. . ; , . . '�' �u�ri � � � ,� �-� —
Subdivision: �� � � �G�Ql� Section: I.ot ^Q
T�e of Water Suv�lv:
Re4uirements•
� es'�e.r c�fi�-� '� --:
✓ Individual Community Public
Site Approved by �/��i�� /� �3/ --��L. �
GroutYng Approved by ��S ► �- u-��.
Well Log�.-.� i �- y'`'Z
Well TagC�s � �-�5--�2 ��z 11 �.r.:kQ.
Air Vent C�S ( I�5 -0 2 '
Hose Bib�-� 1 l �s-o2- `�~' `�� �
Concrete Slab CtS�i ��s-�Z ��5� h�`` �'�' ��"
�ocC�- ,
Well Drille . �^^^e `�`�� ��r.`�.
Well Approved �� �.-, I)ate: I 1- a 5-�a
'�See Attachesi Site Sketch'�`
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from anp building foundation.
O�er conditions• -
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PC�ID, rev. 09/07/01
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section/Lot#
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System com�onents re�iresent alb�roximate�contours only. The coniractor�must, flag the systemprior to
beginning the ir�stallation to insure that j� crde is muintained
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PG�, rev. 09/12/01
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�rou`i Log
Owner: �
Location:
Tax Mapp:/ -/ Parcel # ��
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Subdivision: ,�%� ,�{2v�,L Lot # �_
Well Construction
Distance From nearest Property Line (Minimum 10 feet
Distance from Septic System (Minimum 60 feet)
Total Depth: �_ ft Yield: �� GPM Static Water Level: �_ ft
Water Bearing Zones: Depth /o '�`��ft �'�"� ft ft
l8� z, /ZS /S
Casing:
Depth: From p to 71 $. Diameter: �� in
Type: Galvanized Steel
Weight: Thicl�ess: �,�� Height above Ground: �_ in
Drive Sho�_ Yes No Any problems encountered while setting casing? _�'es� No
If "yes" give reason:
Grout:
Neat: SandlCement
Annular Space Width
Method of Grout: Pumped _
Concr– e�� GraveUCement
inches Water in Annular Space Yes No
Pressure Poured ✓ Depth to Ft.
Materials Used:
No. Bags Portland cement y�, I( 5�� Weight of 1 Bag
If mixture (sand, gravel, cuttings – Ratio � to l
ID plates: ✓ Yes _ No 4 x 4 slab _ Yes _
Drilling Log
4"7 Pounds
No
Location Drawing
From io Formation [j
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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 ealth D partment.
Signature of Contractor ID#� L1 � Date �� D Z--