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Site Evaluation Application Date: � � � � � �
Fee Collected YES � 2d0
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. ���� APPLICATTON FOR IMPROVEMENTS PIItHIT
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1. Permit requested by: ownerf�rospective owner:
agent:
Address:
Home Phone ��:
2. Name and address of rrent owner:
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3. Property Description: Lot size:
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4. Tax`�map ��: } � � Township:
Subdivision Name:
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5. Directions� 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: 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: Exi ing:
Type of dwelling: House: Mobile Home: � Business: _
Type of business: Number of Employees:
Number of bedrooms: Garbage Disposal? Yes No
Basement? Yes Ido If so, number of basement fixtures:
12. Clearly stake all. corners of the property anci the corners of all proposed structures.l,
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. Permiss' n is hereby granted to
enter the property for the evaluation. G.S. 130A-335(F)
Signed Ow r or A horized Agent
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Permit Issued •
Permit Denied
Plat Observed
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i�ACTORS - SITE EVALUATION AREA 1 _ AREA 2 ARFA 3 AREA 4
1. SLOPE (X)
2 . SOIi. TEXTURE (12-36 in. )
(Sandy, loamy, clayey,
Note 2:1 clay)
3. SOIL STRUCTtJRE (12-36 in.
(Glayey soils)
4 . SOZL DEPTfi (in. )
5. RESTRICTIVE HORIZONS (in.
(Impervious Strata. rock)
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SOIL DRAIDIAGE/GROUNDWATER
(�cternal & Internal)
SOIL P�RMEABILITY
(Percolation Rate)
OTHER (speci£y)
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9. SITE CLASSIFICATION ' � jJ�
(See below) �
SOZL SERIES .
S- Suitable PS - Provisionally Suitable U- Unsuitable _
R ECO2�NDATIONS / COMMFSiTS :
S:�:TE CLASSIFICATION JLAGEtAM (Include: Soil areas, property lines. roads, streams, gullies,
Wet areas, fill areas, c�rells. water bodies, slope patterns, etc.)
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVII'ROVEMENT PERNIIT
Tax Map # A� Parcel # J� v`Z
Zoning Township
Owner/Contractor �� rrr� Date o7 S
Location/Address � '
!S7 TL o e n R ''� S#
Subdivision Name Lot#
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SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area g,0 AcreS Size of Tank fxY� _
SFD Mobile Home ✓ Size of Pump Tank !J A
Business �# of Bedrooms � Nitrification Line �`)c 3'
Max Depth Trenches a(o
Permit Void after 60 months
Permits may be voided if s
Well and Septic Layout by
Comments:
Date
. Permit Void if not in compliance with zoning regulations.
Installed by 3$o �.�7P5 Approved by
WELL SYSTEM SPECIFICATIONS _
a op Individual � Semi-Public Required Slab �
�qa� ��'� Public Replacement Air Vent �i _
�,, �." Site Approved � _ Required Well Lo� 1/
Well Head Approved v' _ Well Tag t/
Grouting Approved i/
Comments:
Date �3 a--�-/s' Installed by �rI1��°�,,.Approved by �/,�� ,fl ���-
This report is based in pazt on infocmation provided the homeowner or his/her representative in the apptication submitted for this pertni� 'Ihe
envuonmental 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 &om false or misleading
statements provided to him in the application. Neither Pecson County nor the environmental health specialist wazrants 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 01/95 rev.1.0
ORIGINAL
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PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date: � �19 -9S �
Owner: }���vfv y �1�4r�4 SR#
Lacation/Directions: /3� �L �h��e�e ,���_
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Drilling Contractor: ,E 4�� �J'�G� G
WELL CONSTRUCTION
Distance from Nearest Property Line 2d fy' Distance from ��urce of
Pollution /DD
Total Dep.th: /aD Ft. Yield: O GPM Static Water Level �3� Ft.
Water Bearing Zones: Depth _�Ft. /.� Ft. /� �v Ft. Ft.
Casing: Depth: From �_to 2 7 Ft. Diameter: � Inches
TYPE: Steel � Galvanized Steel Ye,s
If Sceel, does owner approve: Yes ✓ No
Weight: Thickness:�� Height Above Ground:�� Inches
Drive Shoe: Yes �� No
Were Problems Encountered in Setting the Casing? Yes No �
If "ycs" �ive reasen:
Grout: Type: Neat Sand/Cement � Concrete
Annular Space Width t/Z Inches
Water in Annular Space: Yes No ./
Methad: P�?.m�ed Prwsure Roure;d__�
Den�h: FIOm b IC �-� �i. .
Materials Used: No. Bags Portland Cement�_ Weight of 1 ba�___9�`% lbs.
If mixture (sand, gravel, cutcinbs) - Ratio: Z 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 ACCORDANCE WITH REGULATIONS SET
FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT.
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Signature of Contractor Date