A29 162�,
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Site Evaluution Application
Fee Collected YES ✓ NO
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T� e,C�� �U d � APPLICATIOH FOR IHPROVEMENTS PIItrtIT
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l. Permit requested by: ownerfprospective owner:
(� agent:
Address: .�. �n`1.�`�4 RbXb(lfl� ���
Home Phone �� :
2. Nam� and addre�,s of current owrier:
3. Property Description: Lot size:
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4. Tax map ��: Township: ��% �/-{� �l/
Subdivision Name: Lot �i:
5. Directions to property: State Road �� & Road Names, 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: �-�.(o Depth: 4�
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? community?
Other source? (Specify):
Are there any wells on adjoining property?
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spring?
If so, identify location:
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Type of structure aci i. oposed: � Existing:
Type of dwelling House: � _ Mobile Home: Business:
Type of business. Number of Employees:
Number of bedrooms: �_ Garbage Disposal? Yes I�o �_
Basement? Yes No � If so, number of basement fixtures:
Clearly stake all corners of the property and the corners of all proposed structures.I
I tiereby make application to the Ferson 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- 35(F)
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Permit Issued
Permit Der.ied
Plat Observed
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�ACTORS - SITE EYALIIATION
. SLOPE (X)
. SGIL TEXTUEZE (i2-36 in. )
(Sandy, loamy, claye},
ivote 2:1 clay)
,. SOIL STRUCTURE (12-36 in.)
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. SOZL DEPTIi (in. )
�. RESTRICTIVE HORZZONS (in.)
(Impervious Strata, rock)
i . SOIL DRAIIZAGE/GROUNDWATER
(bcternal & Internal)
. SOIL P�RMEABILITY
(Percolation Rate;
. OTHER (specify)
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. SITE CLASSIFICATZ�JN / �
(See belo�a) �� S
SOZL SERIES
S- Sui.table PS - Provisionally Suitable U- Unsuitable
ECOt�4fENDATIO NS / COMMF�TS :
:�.TE CLASSIFICATION �IAGRAH (Include: Soil areas, property lines. roads, streams, gullies,
Wet areas. fill areas, vells, c►ater bodies, slope atterns etc.)
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' PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
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.
T� Map # 1'I� �- 7 Parcel # f�0�
Zoning Township ` .' / /
Owner/Contractor,� , /►/1 u.�Y�.�V Date - 8 %
Location/Address �-I a S ��R o n I-E�S�`S � � 4 �% V/�
; VC�r� 4�9GZd � -f1�e���jl�f S.R.# /�!o �
Subdivision Name � Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area Jp .6U•4 C. Size of Tank 61T1?
SFD i/ Mobile Home Size of Pump Tank N/A
Business # of Bedrooms 2 Nitrification Line o'l �C�' k 3�
Max Depth Trenches / �' � --Zc� "
Permits may be voided if
Well and Septic Layout by_
Comments: �E- s��n+�,�
Date� Installed by,
ell Perru�'t Paid ❑
ite Approved `
�ell Head Approved
�routing Approved_
Comments:
is altered or intended use changed.
by
WELL SYSTEM SPECIFICATIO
Semi-Public Required Slab _
Replacement Air Vent
Required Well Log
ell Tag
Date Installed by.
by
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This report is based in part on info ation provided the hiNpeowner or his/her
representative in the application sub 'tted for this permit. 'I�he environmental
health specialist is not responsible for fa �or misleading information
contained in the application. The environm�ental 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 Ol/95 rev.l.l
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AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: g'a8 ` D/�% IlVIPROVEMENT PERMIT #: JC�� 9
TAX MAP #: '2,q PARCEL #:
OWNER/OWNER'S REPRESENTATIVE: �I �,t. �Y�,
LOCATION/ADDRESS:
� 9 S �T/ 2 n rl �'i � S �-��` `5 5 �-D � � � ,
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SUBDIVISION NAIviE: LOT #
SECTION OR BLOCK:
AVTHORIZATION FOR
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ISSLTED BY:
AUTHORIZATION CONDITIONS
1. The Wastewater system construction and instal[ation must meet all of the conditions of the
attached site plan and speci$cations as set forth in Improvements Pernut #�/ 9,3�. The
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 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:
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Person Requesting:
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Person County Health Oepartment
Existing Sewage System Report For: Hobile Home Replacement
_�Addition --��;�(�y�S
Etequestee: �•�• I V`u. Fiome Phone#��'r i' u(2��p
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� �J�.dU���QiC � 757� 'rax Map� ��?— I (o�
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Location/Uirections: �c� �
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Oriqinal Permit Located �—
Septic System Uesiqned For:
itesidential �/ F3usiness
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Other (specify) _
� Bedrooms � # Employees Other
Uate '1'nstalled % `7 90 Water supply 1'1'l.t�'� `���
Type ot System
Nitri�ication Line v� ! � �c� —
Tank Size
Certified Ogerator Required
On site wastewater disposal system showes na visual.ly apparent
malfunction on _��"'��� . ,
�ermission is granted to:
According to the attached site pl.an.
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A�alication �ate: � � �� Tax �laa #: �i"� �
Amount 3�aid• � � 2�
Recaipt #: Parcai #:
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APPLICATION Ft�R SERVEC�S
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IF 'THE IfVFORflAAT1�N IN THE APP�:ICATIOPV FOR AfV lMf�RO�IEMEPIT PERIIAIT IS INCORREC'9' F:4LSIFIED
CHANGED. OR THE SITE IS AL'fERED, THEiV THE IMPR�VE�111ENT PERMiT F�1iVD AUTHORIZAiIOId TO
CONSTRUCT SHALL BECOME INVALlD. -�
1) Permit requested by: (OvmerlagenUprospective owner): �~
Home Phone: Address: �r v < �
Business Phone:
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3) Property Description: Lot size: / a�. Township: `�"
Directions to the properiy (lncluding road names and num4ers): _
�'"` Lot # —
4) Proposed Use and Structure Description: answer each of the following questions: � 3� /
a) Proposed , Existing �Type of Structure: /�,o,u� Width:� Depth:�
b) Number of Bedrooms: � Number of occupants or people to be served: �` -
c) Basemen� Yes . No �c Will there be plumbing in the�basement7�
d) Garbage Disposal: Yes , No �
5) lAlater Supply Type: Private _(new _ or existing�, Public_, Community� , Spring %/
Are any wells on adjoining property? Yesj�AJo _ if yes, please indicate approximate location on the
�site plan.
6) Does your property contain_previously identified �urisdictional wetlands? Yes_ No�,
PL�ASE NOTE THE FOLLOWING:
➢ A P�AT OF THE PROPERTY OR SI'TE PL�►N NIUST SE SUBMITTED WITH YHIS APPLiCAT10N.
➢ PROP�RTY LlNES AiVD CORNERS MUST BE CLEARLY MARKED. �
9 THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAIKEfl OR FLAGGED.
9 THE SITE MUST BE RF�►DILY ACCESSIBLE FOR AiV EVALUATION �Y THE liEALTFI DEPARTMEAlT
STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposai
system for the above-described property. I agree that the contents of this appiication are true and represent the maximum
faciiities to be placed on the property. I understand if the site is altered or. the intended use changes, the permit shall
become invalid. �
-- ,� -" � `�..
Date
PCHD, rev. 06127/02
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ZC�ena-�,•-,,,*,�• osa�mll �'IL�.�.71��a
WELL PERMIT
PI.EASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: �.� Parcel # I� a Townslup O I i V c. �-{ c I(
Applican� tt"� � A, (11 c.�r rc�j
�lL J(11 Ur��y- l-� a z{/ Q. d. � c� Tv E�
Ty�e of Water Sun�Iv: �Individual Community Public
Re�uirenlents:
Site Approved bp ✓3� I O- j�-o�
Grouting Approved bp ✓�Ik t o� o`�:�
Well Log ✓3 �4- � o -� o --o-�-
Well Tag
Air Vent
Hose Bib
Concrete Slab
Well Driller.
Well Approved Bp: Date:
'�See Attached Site Sketch**
Wells must be 10 feet from propertp lines.
Wells must be 100 feet from septic systems.
Wells must be ax least 25 feet from anp bu�ding foundarion.
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PCfID, rev. 09/07/01
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SITE SKETCH
e H e ��Y . A.�Il,� r�a,r �Tax Map # a� Pascel # ��-�
ub ' io � Section/Lot#
8 a(� -oa
Authorized Sta.te Agent Date
System components represent a�'iproacimate contours anly. The contractor must, flag the system prior to
beginning the installation to r.'nsure that propergrade is maintained
nt t t' IG: 2° • E. -� —�..39. 22'
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Owner: ,l�t��y �A�l�,,,�ya,� Tax Map ,?�' Parcel # r� �
Location —
Subdivision:
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�� ft ft ft ft
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Casing:
Depth: From �_ to � ft. Diameter: � in
Type: Galvanized Steel � ,��
Weight: Tluckness: �,I $� Height above Ground: f� in
Drive Shoe: Yes No Any problems encountered while setting casing? Yes i/�io
If "yes" give reason:
Grout:
Neat: Sand/Cement _� Concrete GraveUCement
Annular Space Width inches Water in �inular Space Yes No
Method of Grout: Pumped Pressure Poured Depth to F�
Materials Used:
No. Bags Portland cement Weight of 1 Bag Pounds
If tnixture (sand, gravel, cuttings) — Ratio to
ID plates: Yes _ No 4 x 4 slab _ Yes _ No
Drilling Log � Location Drawing
From To Formation
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I hereby certify that the above information is co ect and that this well was constructed in accordance with regulations
set forth by the Person County Health De nt.
Signature of Contractor .� �� ID# s%� Date /Q-�i D,�
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