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, � APPLICATION FOR SERVICES
1. Permit requested by:
ome Phone #:.
usiness Phone
..� yr
Name and address of current owner:
Lot size:
7. Dimensions or Proposed Structure:
� i �,N� Width: 2 �
Depth: (o O
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?
Nd��
cssi� � 9. Water su ply type:
private public ❑ community ❑ spring ❑ ,�/
Are any wells on adjoining property?Yes ❑ No L�J
If so, identify location:
Tax Map#: � � `j j, o-� �
Parcel#: N.; ( IkA�
Township:
Directions to property: State Road #& Road
ames, etc.
.
:, (-� o �
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Number of occupants or people to be served: Z
10. Type of structure/facility: Proposed: �Existing: ❑
�ype of dwelling:
House: ❑ Mobile Home: Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �,��,/
Garbage Disposal? Yes ❑ No L�
Basement? Yes ❑ No Q'�so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pei'SOn COunty Health DepBi'tment 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 Dept. I understand that in the event I have not
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
���----�. �
z Signed Owner or AuY�iorize� Agent
Permit Issued L7
Permit Denied ❑
Plat Observed C4�
�����;� ��
Signature � �y� ���fbate
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': ` FACTORS-SIi'EEVALUATION. ': ATtEAl ... .;; "'; AR£A2';:::. i ..: AREA3 ' iAREAd '': „ '
I. SLOPE ( k) S S S
PS �✓,�� PS PS PS
U U U U
2. SOII. TEXNRE (12-36IN.) S S S S
(SANDY. LOAMY, CLAYEY. NOTE 2:1 CLAY) PS �f(�� PS PS PS
�4 .1-�'— U U U
3. SOiL S7RUCil1RE (12-36 IN.) S S S S
(CLAYEY SOILS) � PS PS PS
U U U
4. SOIL DEPTH (IN.) S S 5
PS �� N PS PS PS
U U U
i. RESTRlCI7VEHORIZONS(INJ S � S S
(IMPERVIOUS SiRATA. ROCK) P �� PS PS PS
U U U
6. SOIL DRAiNAGFIGROUNDWATER S S S S
(IXIERNAL & IN7ERNAL) S 0 PS PS PS
U U U
7. SOIL PERAIEABILI'iY S S S
(PERCOLOATION RATE) PS � A'�— PS PS PS
� U U U
R. AVAII,ABLE SPACE S S S � S
P v 1C PS PS PS
U U U
9. SIIECLASSIFICATION(SEEBELOW)
SOIL SERIES
S-SUITABLE PS-PROVISIONALLY SUITABLE U-UNSUITABLE
RECOMMENDATIONS/COMMENTS:
STTE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.� C:WNiPRO�DOCSIAPPSEC.SMFINANCE.PC
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT 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
lias been issued.
Tax Map # � � �
Owner/Contractor
Location/Address
Subdivision Name
Parcel # � (v
Township S' y � y
i�/'l���S ate �-/3- 9,C
o., /o�'� ��.s,f -r/L>/��/
,,_ S.R.#
Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area G C� Size of Tank ��' .f
SFD Mobile Home Size of Pump Tank n�l/-�
Business # of Bedrooms� Nitrification Line 1�p�� �)( 3�
Max Depth Trenches � � ��
Permits may be voided if site is altered
Well and Septic Layout by
Comments:
Date_ �-��%- �� Installed by.
Approved by
_ Well Permit Paid [� WELL SYSTEM SPECIFICATIONS
� Individual Semi-Public Required Slab _
Public Repl cement Air Vent
� Site Approved I� Required Well Log
Well Head Approved � Well Tag
Grouting Approved
Comments:
Date
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 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 warrants that the septic tank system will continue to function
satisfactorily ia the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
' (Void sixty (60) months from date of issuance)
DATE: �� �� -�� IMPROVEMENT PERMIT #: O I�
TAX MAP #: PARCEL #: ���-
,
OWNER/OWNER'S REPRESENTATIVE: ' � '�
LOCATION/ADDRESS:
SUBDIVISION NAME:
SECTION OR BLOCK:
LOT #:
AUTHORIZATION FOR CO�TSTRUCTION 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 # ��9. 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 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:
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;�u� � PROPOSED DIVISION ��� • ' `
� R � /Z Acc.Es
� H I L L HA VEN ,��1
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.� ' BUSITY FORK TWP., PERSON COUNTY, NC
OCTOBER 1994, HA�ILETT-JENNINGS & ASSOCIATES
� o �o0 200 400
BAR GRAPN 1 inch = 200 fi.
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PERSON COUNTY ENVIRONMENTAL HEALT'Fr .
WELL LOG
Date: � aC.�
Owner: �
• Lacation/Dire�
,
SR# _/fl Z
Subdivision Name: _ ____ !-� � ,1 _ Lot # /
Drilling Contractor: � e
WELI. CONSTRUCTION
Distance from Nearest Property Line O' Distance from Source of
Pollution /Dv'
Total Dep.th: f� ' Ft. Yield: /�v' GPM Static Water Level Ft.
Water Bearing Zones: Depth .3�Cp Ft. Ft F� Ft.
Casing: Depth: From C to `3 � Ft. Diameter: �` Inches
TYPE: Steel - Galvanized Steel ��
If Steel, does owner approve: Yes No
Weight: Thickness: ,/�'� Height Above Ground: /� Inches
Drive Shoe: Yes No '
Were Problems Encountered in Set�,ng the Casing? Yes •' : No ---�
��- , .
If "yes" give reason: �'
Grout: Type: Neat Sand/Cement �r . Cor�rete
Annular.Space Widch �""'�-�iches r
Water in Annular Space: Yes �-No �' �
_.. Method: PLmped . a Pressure Pou��d .
`-!' . .
Depth: Fr�m Q �o �a Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag lbs.
If mixture (sand, gravel; cuttinas) - Ratio: to
ID Plates: Yes No � �
4 x 4 slab Yes No
I HEREBY CERT'IFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON CO'Ji�I'Y HEALTH DEPARTMENT.
Signature of Contractor Date