A31 125Site Evaluation Application
Date: � /� ' ��
Fee Collected YES V NO
�
2
o`� �`�� APPT.ICATIO2J FOR IMPROVE!•fE@iTS PEitPiIT
� / \��
l. Permit requesteci by: owner/prospective owner: ��
agent:
Addres s : t �/y' � �� C_7� � -
Horne Phone ��: .g'-9 �- �, ='�.�9 Business Fhone �6:
2. P7ar�e and address of current owner:
i. Property Description: Lot size: „�,J� ���
I y5 �
4. Tax map ��: � � Townshi :
Subdivision Name: �s
5. Birections to property: State Road �� & Road Names, etc.
< 74 . 1 I / eZ _ /% �i d �. � _ ' � _ �.+� o—„�
0
Lot ��:
E. Permit requested for: New Installation: i/� Repair:
Additional Renovation re-using present system:
z
� �' '� ,�.u� �
� �
.� oa3 `�
— l �
�� � v
r • \
�
�
7. Nu�ber of occupants or people to be served: �.yto'�-�woW� � F'
/So U � �' a`a�
i
i3. Dinensions of Proposed Structure: i-�idth: Nn'� �'notA� Depth: �p� ,�,�)��,va(
9. What type (if any) additions, expansions, or replacement is antieipated to the struc-
ture ar facility that this sewage disposal system is intended to serve?
� �%� w
�
i �
a
10. Water supply private? ��� public? community? spring? ..�
�
Other source? (Specify):
Are there any wella on adjoining property?
. ,. . , , ,
11,
�- If so, identify location:
Ty�ie of strucfiure or facility: Proposed: ✓ Existing:
Type of dwelling: fiouse: �i " Mobile Home: Business:
Type of business: Number of Employees:
Nunber of bedrooms: 72.�7` .t/au� Garbage Disposal? Yes No
�asement? Yes No If so, number of basement fi�:tures:
12. Clearly stake all corners of the property and the corners of all proposed structures.
I hereby make application to the Person County HealtYi Department for a site
evaluation or existing system evaluatian 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 inval�d.
Permits are valid for. 60 months fram date oi issue. Permission is hereby granted to
enter the property for the evaluation. G.S. 13QA-33S(F) �
. .l�G�-= .
Sign Owner r thorized A�ent
m
�
�N
r �
0
�
m
�- � �- y��„��., s� c�r�„�
rermit Issued v-+1 /(��
I
Permit Denied
_�lat Observed ,�
\
�c� � -� ��i
"�
, � f
� . � a�0. �j �
�- �,'�`��„"� � �'`'"r°�
� �
� Q,,t�. '��
� �� �� ���
a -r6 -q �-- 1, o -�-�f�tl
1CTORS — SITE EVALUATION AREA 1 AREA 2 � 3 �iREA 4
S -
. SLOF£ (�) PS PS PS P5
u u u u
. SGL:. TEXTURE (12-36 in. ) S S S S
(Sa�d�, loamy, clayey, .
Pio te 2:1 clay) U� �� U � �`_� � U �`�
. �OIL STRUCTi1RE (12-36 in.) S S S S
(C�.ayey soils) � � �
u �� u 3� �-�.� U 3v
- � s s s s --
. SOIL DEPTfi (in. ) �_ � �
u c-� u � a U 3� u
e RESTRZCTIVE HORIZONS (in.) S S S S
(IQervious Strata, rock) � � �_ �
U U U U
. SOIL t�RAI2IAGE/GRO TER S S S S
(bcternal ternal c�— � __ ��i '
U U U U
o�S�IL PERMEABILITY S S S S
(Percolation Rate) PS PS FS P5
U U U U "
S S S S �
. OTKER (specify) PS PS �'S PS k
r U U U U
.. S;rTE CLi�SSZFLCAT7CON
(See beloc�)
SOIL SERZES
S— Suitable PS — ProvisionaZl Suitable U— Unsuit�ble ^
ECt�i-41Ei1DATIONS/CAMMErITS: S Srt;�/ � I � ' [� , �,�i
4'�-CG� �il %��Q-Gta te,_ . r � G-/ � �
:�:T� CLASSIFICATZON D GR��i (Tnclud�.a Sail areas, �roperty line�, roads. �trea�►s, ,u31�as,
�tet ar�as, fill areas� W�ils4 � taodies, ��ope patterns, etr_.)
.y(1�.Q�—u�.�`-�
�son County. Health Department
Sewage System Improvements :P.er.mit
Date: � � � U' v! 1
Own.��—�
T:ocation/Direcdons:
ns ermit Void After�5 Years Permit-# ��»" a`E0 �
P� _ �/Y� SR# i 1�
Subdivision Name: w� r c.�r,�,�,�� Lot # �
Lot'Size: ��T) ((,j:�6/P,i � Typ� of Dwel �
Water �Supply: .. vate: _�,�. Public: Community:
Bed�ooms: P�_� Gazbage Disposal
$asement � � � - Basement ix � . - -
INFORMATION. CERTIFIED BY� �
Environmental'Health Specialis:t: ` ' �, "7e : `
.�m
REPAIIt: � � _ . REEV A ; N: . �`J
.. , '. . � y�,y�
Y�
Size� of Se�p�— ----- n Size of Pump. jank: .— -
Nitrif'ication-Line: � �
Depth of Stone: � 12 inches �/
Iv1ax Depth of Trenches: � ` . ._ .. __ ,� ��
Altemative Sys�j - Gonv...Pump LPP Pump :. b�..... �'O e
Remarks: 1/_ ., n �i�r� ,i� , � f r�n�— � .. _ ,1
_ _ '
� "' �i� .. ': �. ' ' . �l.:. _ .:..'�.. _.>: . � .� :,: .. . .L':�.� /S.; � :
_ ` - � ' , ' ' . . '
Date ell.Ap ed: '�� `�� Well shQu�d..be:1QD;ft...from.any sewer.system
BY_. -- ' ,nv' nmen Health Specialist :
' _.��,.�' . �-}i'.-..._ ._ • ,
Date age S s' Approved: ��
BY�� � __ vironmental Health Specialist
�
�
- CERTIFICATE OF COMPLETION ,..�
Contractor. �t,,��.�-� . � ' • �
-----------�----------------- ��
Sewage System location, installauon, and protecdon must meet state and local �
regulations. Septic tank shoulfl be pumped out every 3 to 5 years'and shall be maintained
by owner in sucfi manner'as nof:to ciea[e� a pulilic':fieaTth liaz'ard: Se�piic"tank;and �
nitrification;line...must.be_inspected..and.appro�ced .by..:a.membei of the_Person._Counry
Health Department beforp any portion of the installation is ;coveied and ptrt into use. If �
�the:site plans: or�intende2i�itse Ci�2nge this peiiriiC is'subjecCto�revocation:. ., . ; . _. ; `
.�G.S.130A335F)_..'....._� ....:.._ � _.: _.._:. .._,.. ._.•_ �
I.oaatian of sewage-dispo:sal-sewage sysCem-sketched-on back: � • •`•�- -�
_ ° • ' �
, . ._ . _ _ ..... _. . __ --.. _... .. _... _. ._. . .. ._ _ . ...
(OVER) . . . .. . ..
°�erson County Health
� � Well Permil
' Date:.�� is Pcrrtut Void pfter 5 Ycars
: Owner. 1•( V✓c�
Subdivision Name:
Drillirig Contractor:
Department �
�
sR# % %IZ �
Lot#
WELL CONSTRUC'I'ION
Distance from Neazest Property Linem;� � d., . Distance from Source of
Pollution_ M1x l.b'� ' '
Total Depth: 1 e� Ft Yield:_! 2 GPM Static Water Levell�Ft
Water Bearing Zones: Depth r l.'.t Ft 5. �7 Fc4 73 Fc FG
Casing: Depth: From b to FG Diameter._ L*+ches
TYPE: Steel Galvanized Steel ✓
� If Steel, does owner approve: Yes ti' No
WeighC � Thickness: Height Above Ground: GYl.� Inches
Drive Shoe: Yes ✓ No
�JVere Problems Encountered 'm Setting the Casing? Yes - No -•
lf "yes" give reason� —
GrouG Type: Neat Sand/Cement �� Concrete
Annular Space Width ) � Inches
Water in Am�ular Space: Yes No ✓"
Method: Pumped Pressure ' Poured :i
L�epth: From d to �bi' _Ft
Materials Used: No. Bags Portland Cement Weight of 1 bag__lbs.
If mixture (sand, gravel. cuttings) - Rauo: : 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 AGCORDANCE WTTH REGULATIONS SET
FORTH BY THE PERSON COUNTY HF,A�.TH DEPARTMENT. �.I
�i
�"�
�� `i�Shc'^'�� '� ��
��
1,• ��.,,1 r.-�.�_
ikc�cli w•�•II luraii��n nn r�.•�•��rsr si�Jr.
�� ���
t A � �
� Date
_�n;�/�
. __. .� _.
llatc Issucd
i�7��5
D:llc Complcicd
------__"---- --
Ryy,
'f1-.
c
i
L