A31 147Site Evaluation Application
Fee Collected YES �
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APPLICATIOid FOR IMPROVEMENTS PIItHIT
1. Permit requested by: owner;;�rospective owner:
� agent:
Ad dr e s s : (j � � . }�� -r�L � � U /1 �+u-�.dC� ?�✓LC�-G
Home Phone �� • ��T - y,y'rT_ Business Phone ��:
2. Name and address of current owner: 5�} �i/J�
3. Property Description: Lot size: .��i�ro�C �-� �cr�S �d�� 383 �C�'eS�
4 . Tax map ��: � 3 a� °2" \ Township : ,�. �
Subdivision Name: _ Lot ��:
5. Directions� to property: S
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oad Names, etc.
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6. Permit requested for: New Installation: _r� 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? community? spring?
Other source? (Specify):
Are there any wells on adjoining property? � If so, identify location:
11, Type of structure or facility: Proposed: � Existing:
Type of dwelling: House: �' Mobile Home: Business:
Type of business: Number of Employees:
Number of bedrooms: � Garbage Disposal? Yes ro
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
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)
� Si ned Owner or Auth izen Agent
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Permit �Issued
Permit Denied
P at rved
S�b a� x 3� 3.�� �,
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i�ACTORS - SITE EVALUATION
1. SLOPE (X)
2 . SGli. TEXTURE (i2-36 in. )
(SandS, loamy, �ey,
Note 2:1 clay)
? SOIL STRUCTURE (12-36 i.n.
(Glayey soils)
4 • SOIL DEPTH (i.n. )
5. RESTRICTIVE HORIZONS (in.)
(Impervious Strata� roc.k)_
6. SQIL DRAZNAGE/GROUNDWATER
(bcternal & Internal)
7. SOIL PERMEABILITY
(Percolation Ratc)
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AREA
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8. OTHER (specify) PS PS PS PS •
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9. SITE CLASSZFICATZ�JN
(See beloW)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R F_COt�4gNDATIONS /COMMErITS :
S:�:TE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines. roads, streams, gullies,
Wet areas, fill areas, wells. water bodies, slope patterns, etc.)
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PERSON COUNTY HEALTH DEPARTMENT
A..01 �5
WELL SEWAGE SITE, LOCATION IMI'RO NT PERNIIT
Tax Map # �, Parcel # � 4�'�
Zoning Township ��ti ��z
Owner/Contractor ., • S 1, err � r N� Date �-�- 9 S
Location/Address � ►��'. . �� � �-�-�
�� /��rr,-.-t l�-G..w-�, / -5 `Z_ S.R.# 3
Lot#
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or intended use changed.
Well and Septic Layout by Gv -�—e 1�
Comments: ___
Date c3 -25- �'�C Installed by
Approved by,
WELL SYSTEM SPECIFICATIONS
Individual 1/' Semi-Public Required Slab V
Public Replacement Air Vent
Site Approved 1/ Required Well L� _
Well Head Approved Well Tag
Grouting Approved
Comments:
Date ,S'-� - q� Installed by E v��l �n(c c L c� � Approved by
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this pennit. The
environme.^.tal health specialist is not responsible for false or misleading infotmation contained in the application The environmental health specialist
is also not responsible for concealed conditions on the property or for statemenis in this report that may have raulted from false or misleading
statements provided to tum in the application Neither Puson Courrty nor the envirornnental health specialist wairants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable.
ORIGINAL
c:�amipro�peimitsam Ol/95 rev.1.0
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I'IiIZSON COUN7'Y 1•:NVI:IZONM1sNTAL IILALTfI
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Date: . �=� �
Owner: _ .jZ t�l ; . ��{ ��
Location/Du-ections: �;_��.��
IJh:I,L LOC
(�1 r� n .,�
��L:'.:vision N�u»c: . -_-�—.—�----------- Lot��
Drilling Cona-actor: ����_l,�_��_�_�p��—�-"
WEL.L CONSTRUCI'I N �
Distance from Ncarest Prop<:rty L,ii�� /� �„S llis�ancc from Source of
Pollution o c� ,,�,, .
Total Dep.th: ' Ft. '�icld: GPM Static Water Level Ft.
WaterBearingZones: Dept!��__Ft. I:t. F[. �t.
Casing: Dept}l: From __�to_.___,�_�Ft, lliameter: �� Inches
TYP�: Stcel Galviutizccl Stecl .� �
If Steel, docs owncr approvc: ycs No
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Weigh[;�_'�',lickness:____����iglit Abovc Ground:_ /� Inches
Drive Shoc: Ycs_ � No �
Wer� I'rob1ei11s Encotin[crcd in Scttinb thc Casing? Ycs No
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�c .�ycs" give rc:isoii:
Grout: Type: Neat Sanc3/Ccmcnt � Concrete ���
A.nnular. Space Wiclth 3 jnc}l�s
Watcr in Annular .Spacc: 'k'cs N� �_. �
Mcthod: Pumpcd 1'rc:ssu�-c I�ourcci .._-- �
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Dcpth: From Q t�— ��_ t:�- �" .,.,
Materials Used: Nu. Bags �'ortlan� Cement__�___ Weight of .1 bag�lbs.
Yf mixturc (sand, gravcl, cuttinos) - Ratio: �-- to 1
�ID Plates: Yes � N� � � . � . .
� 4 x 4 slab �Yes ✓ No '�
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I HEREBY CERTTF�` T�-IAT'I'HE AI30VE INFORMAT.[ON IS CORRECT AND THAT� �'�'
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T�S WELL WAS CONSTRUCTEI� 1N A,CCORDANCE WITI-I REGULATIONS'SET� �� „�,�,-.'ss
FORTH �3Y�THE PEI2SON COUNZ'�' I-IEALTH DEPARTMENT. f�,4�
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b ontr,�ctor Datc ������
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