A29 160. - ' '
S�te Evaluation Application
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APPLICATZON FOR IHPROVII�lENTS PIIiHIT
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1. Permit requested by: ownerf�rospective owner: ��
`\ ` agent:
Address: �•� � o� 1Q 3 1�1� ( C�!`e �; 1 �.S �� C
Home Phone ��: � -�I�c� Business P ,tone �r`:
2. Name and address of current owner:
�-� �- f�T�V � Yf�'L C� Ilv �J ��l C, �" '�
3. Property Description: Lot size:
4. Tax map ��: � 1 �%V Township:
Subdivision Name:
5. Directions to property^ State Road �� & Road Names, etc
Lot ��:
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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. Water supply private? public? _
Other source? (Specify):
Are there any wells on adjoining property?
community? spring? �
�� If so, identify location:
11, Type of structure or facility: Proposed: Existing:
Type of dwelling: House: Mobile Home: iC� Business:
Type of business: Number of Employees:
Number of bedrooms: �_ Garbage Disposal? Yes No �
Basement? Yes No �_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)
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Signed Owner or Aut rizec� Agent
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Permit Issued
Permit Denied
Plat Observed
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- SITE EVALUATION
1. SLOPE (X)
2. SGIL TEXTURE (i2-36 in.)
(Sandy, loamy, clayey,
Note 2:1 clay)
3. SOIL STRUCTiTRE (12-36 in.
(Clayey soils)
4- SOIL DEPTH (in.)
,5. RESTRICTIVE HORIZONS (in.,
(Im�ervious Strata� rock)
6. SOZL DRAIi1AGE/GROUNDWATER
(bcternal & Internal)
7. SOIL PERMEE�BILITY
(Percolation Rate)
g . OTHER (specify)
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9. SITE CLASSIFICATION
(See below) S
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECO2�NDATIQNS / COMMF�ITS :
S:�:TE CLASSIFICATZON �IAGRAM (Include: Soil areas, property lines. roads, streams, gullies.
Wet areas. fill areas, c�ells. water bodies, slope patterns, etc.)
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PERSON C�UNTY HEALTH DEPARTMENT '� 0 912
�� . WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # /��q Parcel #
Zoning Townshin (��,'V2. %�i /
Owner/Contractor 3� e 17�r� na- �� ze � Date I�—� ��,=yT
Location/Address t-t-� S.f�, s� r� � l� �_t.., s2� 1163 _ ,. _�
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Subdivision
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S.R.#�
Lot#
As Installed
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SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area_ �1. (p 5f I �3 �' �
SFD Mobile Home ��
Business # of Bedrooms�._
Size of Tank r G' �.�'! �'
Size of Pump Tank �//A
Nitri�cation Line� � �.�,� `
Max Depth Trenches
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or ' nd e c nged.
Well and Septic Layout by ,I
Comments: �
,���z,� ..�-i�'-9
ell Permit Paid
Installed by
WELL SYSTEM SPECIFICATIONS
by
Individual Semi-Public Required Slab _
Public eplacement, Air Vent
Site Approved Required Well Log
Well Head Approved Well Tag
Grouting Approved
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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 faise or misleading information contained in the application. The environmental 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 wa�rants that the septic
tank system wili wntinue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro\permit.sam 01/95 rev.1.0
��� � m n C _��I(���-: �' � � _ �
PERSON COUNTY ENVIRONMENTAL HEALTH
�: ._ . ., � ' WELL LOG _ : _ •
Date: s � '
Owner:So� h/a,�ze�
Location/Directions:
SR# //�3 �
Subdivision Narne: __ Lot #
Drilling Contractor: _ l�e.�i-k he f,��
WELL CONSTRUCTION
Distance from Nearest Property Line /'p Distance from Source of
Pollution_ /oC�`
Total Dep.th: 024o Ft. Yield: �O� GPM Static Water Level Ft.
Water Bearing Zones: Depth a�'�Ft. Ft� F� Ft.
Casing: Depth: From C� to �� . Ft. Diameter: �/y Inches
TYPE: Steel � Galvanized Steel �
If Steel, does owner approve: Yes No
Weight: Thickness: ,/�� Height Above Ground:�_ Inches
Driv�e Shoe: Yes ✓- No � .
Were Problems Encountered in Setting the Casing? Yes No ��
If "yes" give r�:ason:
Grout: Type: Neat Sand/Cement �--- Coricrete
Annular Space Wid[h 9 Inches '
Water in Annular Space: Yes No .� �
._ Method: P�.�mped . . Pressure Fo�ed �--
Depth: Fr�m C� �o �.CG Ft.
Materials Used: No. Bags.Portland Cement Weight of .l bag lbs.
If mixture (sand, gravel, cuttinas) - 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 PERSO�' C^vUi1"I'Y HEALT DEPARTMENT.
Signature of ontractor Date�