The URL can be used to link to this page

A29 39_ �erson County Health Department �ewa.ge System Improvements Permit Date:��'� This Permit Void After 5 Years Owner: _� �< e./ b 1 � v•P4- Location/Directions Subdivision Name: Lot Size: � Water Supply: Bedrooms: � Basement INFORMA < $f1111[az1811: REPAIR: z � � � G�° ype of Dwelling: �.�h1�r r�� Garbage�sposal Basement Fixtures BY owner or representative EVALUATION: Size of Septic Tank• �/�� gallons Size of Pump Tank: ---- -------- . -��s=b'{7c- � � Nitrification Line: Depth of Stone: 12 inches Max Depth of Trenches: Alternative System: Conv. Pump LPP Pump Remarks: Date Well Approved: Well should be 100 f� from any sewer system BY Sanitarian Date S wage S stem Ap ved: �n -�j' `� � BY �� Sanitarian CER TE QF COMPLETION Contractor. ---- — ----------------- � Sewage System location, installation, and protection must meet state and local '� regulations. Septic tank should be pumped out every 3 to 5 yeazs and shall be maintained � by owner in such manner as not to creaie a pubiic health hazard. Septic tank and�d nitrification line must be inspected and approved by a member of the Person County � Health Department before any portion of the installation is covered and put into use. If the site plans or intended use change this pennit is subject to revocation. (G.S. 130 A-335F) Location of sewage disposal sewage system sketched on back. (OVER) r _ � �.�`" � �''� �✓ • F�erson County Heaith Department � Well P�rmit � Dat� 3-zz ;q�. This Permit Void After 3 Years '� Owner: i�',��, V� o�i __ f� ( i i/o.i-_ SR# �_% �;,�_ LOC1U0[1/Dll'eCti0I1S: �Nev ' �� Subdivision Name: Lot # Drilling Contracwr. _ 1= �. �.- � c (,�t1 �- J � �j WELL CONSTRUCfION ►b Distance from Nearest Property Line�� Distance from Source of �' Pollution a u- ;�, Total Depth: Ft Yield: �_GPM Static Water Level c�?�Ft � Water Bearing Zones: Depth $� FG 1[,1- F� � FG Ft. Casing: Depth: From �_ to �.� FG Diameter: %' Inches TYPE: Steel Galvanized Steel v� If Steel, does owner approve: Yes No WeighG ��3 Thiclmess: Height Above Cnound: �Inches Drive Shce: Yes L� No Were Problems Encountered in Setting the Casing7 Yes No If "yes" give reason: � Gmut Type: Neat ✓ Sand/Cement Concrete Annular Space Width ,'3 Inches '' .; . Water in Armular Space: Yes No ` Method: P�mped Pressure Poiued � Depth: From _� to '� c� FG Materials Used: No. Bags Portland Cement �• Weight of 1 bag � Ibs. ff m'vcture (sand gravel, cuttings) - Ratio: Z co � ID Plates: Yes c� No ►d 4 x 4 slab Yes '� No � I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W1TH REGULATIONS SET FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. Date 3%aZ �� Date Issued Sanitarian's Signature Date Completed Sketch well location on reverse side. r NOTE+: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water - - • supplies, etc. Note special problems existing on 1ot. Write in measurements in order that installations may be located ' at later date. Note location of water supplies on adjacent lots. (1) (2) �i`� t < < w �. V . °►6°� � a U � a � i�.-�-�� 1 Improvements Permit (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing) t. . . . Improvements Permit (Unrecorded Lot) Repair/Replace existing Septic 5ystem Improvements Permit (Mobile Home Replace) Permit for New Well Improvements Permit (Addition) Replace Existing Well _ Bacteria _ Chemical 1. Permit requested by: owner/pros ective owner/agent: —�� d"`'� A dres,s :�%�i' v��✓c� �o�P 05� �Gi� r o 11 C. a^l � 7-3 Home Phone #�� 5 17-�SO� Business Phone #: — _ Petroleum � _ Pesticide � Lead 7. Dimensions or Proposed Structure: Width: o� �S 1�� 0.�- Q a ub �� Denth:__ ��e w� de w/ �O`�W� ` M. ��I- What type (if any, additions, expansions, or �lacement is anticipated to the structure or facility t this sewage disposal system is intended to serve? Name and address of current owner: �4 rh � 9. Water supply ty�pe: private � public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes � No,� If so, identify location: Tax Ma� Parcel#: Townsh �n: Lot size: _ 2 � 1; " e 1�- � . Directions to property: State Road #& Road ames, etc. S'� ��- � T�� . 7 %�cSi�/S7�ez- �� • - %� O�'7 D�v�T L�,� R�. Number of occupants or � i`5o�rii/�c S7vir j(J _ f�GtG � /m/ IC. `f- a�- � C a bcl, ��Z r+: % ox eople to be served: f' 10. Type of structure/facility: Proposed: �Existing: �' Type of dwelling: Se�� -� House: ❑ Mobile Home: �1 Business: ❑ Type of business: Number of Employees: Number of bedrooms: 3 Garbage Disposal? Yes ❑ No C] �asement? Yes ❑ No � If 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 Depal'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. � �.� � a,0�� Signed Owner or Authorized Agent Permit Issued (-1 Permit Dei _ r��l Plat Observed ❑ Signature Date PACfORS-St3'H EYALUA770N AR�i 1 AREA 2::: AREA 3 AREA 4:: _ .__ . _ _ _ _ l. SLOPE ( k) S S S S PS PS PS PS U U U U 2. SOIL, TEXNRE (12-36 IN.) S S S S (SAtv'DY, LOAMY, CLAYEY. NOTE 2:1 CLAI� PS PS . PS PS U U U U 3. SOI[. STRUCIURE (12-361N.) S S S S (CLAYEY SOILS) PS PS PS PS U U U U 4. SOIL DEPIH (IN.) S S S S PS PS PS PS U U U U 5. RESTRIC(7VEHORIZONS(IN.) S 5 S S (�iPERVIOUSSTRATA,ROCK) PS PS PS PS U U U U 6. SOQ.DRAINAG&GROUNDWATER S S S S (EXTERNAL dc INTERNALI PS PS PS PS U U U U 7. SOII. PERMEABILITY S S S S (PERCOLOAT[ON RA7E) PS PS PS PS U U U U 8. AVAII,ABLE SPACE S S S S PS PS PS PS U U U U 9. SITECLASSIFICATIOV(SEEBELOVI� SOIL. SERIES � S-SUIYABLE PSPROVISIONALLY SUffAaLE U•UNSUITABLE RECOMMENDATIONS/COMMENTS: SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope patterns, etc.) C:WAIIPRO�DOCS�APPSEC.SMFINANCE.PC � � � W U � a B0151 PERSON 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 # Zoning Township Owner/Contractor Location/Address Subdivision Name .�- Lot# Date / Z — '7- 9� S- � s � ,. � . S.R.# „ � � SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area /Q� ��crt,r Size of Tank w�;'r�t �/oD� SFD Mobile Home Size of Pump Tank NI /� Business # of Bedroom� Nitrification Line �'fe�,�r �p0 X3 Max Depth Trenches Permits may be voided if site is Well and Septic Layout by Comments: �e ��,,,}- �� y_L Date _ Installed by Well Permit �d ❑ WE Indivi Se ' P �c eplacen (r Site Approv C� Well He Approved � Gr ng Approved Comments: Date Installed by. a ed r i tei ded use anged. 1R cQr � , �f � w, �1 � w+,e.s:.Q� Approved by. � r . S E ECIF C TION c Requi d Sla rt Air ent R uir Well og _ el ag 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 in the future or that the water supply will remain potable. c:\amipro\permit.sam O1/95 rev.l.l � \ � t �; � J O O � r �s �� r} g Z V N � j �� o��o O N N � � V � ��NALD .L • OL J 1/E� .ZG A�• T.��/cT � L� £� / �� 8 q .2� 48`�. � 01' eo w ,,,� W,. Q. 3 •� g,�� r 3� �4 � --- g 12 ' 1 G � s+ w , �� a ,' .. '-,�RSEY L. �' DEBdi�+-i T �L��/EEZ