A32 12The Disfricf 1-�ealfh Departmenf
Orange, Persoa. Caswell, Chatham, Lee Couaties
SEPTIC TANK PERMIT
DatP C� i� 1�11 O t-(%�� W I�b- L�
Name of owner: �d.� � � i�a 1 n
Name of contractor: �':f C� W 61"1 � 1"L �� P. �C1
Address and Directions ��-� � l i rnb��rK� �C-+
Ot���'�, OF Dc�c� �n�� R�� #� (18�-
Person or firm doing installation: —�
Address .
No. of persons to be served Bedrooms 1, 2,04.
Additional appliances to be used: Disposal, dishwasher, washing
machine
Recommended• � Septic tank—��� O D G'�
Nitrification line: � v �' ,�_T!�
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line must be inspected and
approved by a member of the District Health Depaztment staff before
any portion of the installation is covered.
Date Approved: �— y� �' ��
By:
Signe�
Sanitarian
O. David Garvin, M.D., M.P.H.
District Health Officer
Countersigned
(Over)
�Io-i'ca -- T�,� 5 c� �i-er�n V�'as ►�c� .�n� j� e c� c� ?�h e t�
tn�-uli�c� _ �tnc� ��n�� -�-h� So�t con�'��-�or►s urg
cjood �i-h� Wa,�h�r W�II b� on �1-h� .yy�karst un�'�11 �hc�(
huv� Youb1¢ --Th¢ Atior¢ �,�n,� +✓�il b� c�dd�, F
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s�iJTE: Make etch of installation showing location of house, septic tanks, privies, water supplies on:
�� ►~ adjace property, etc. Write in measurements in order that installations may ;be located at later �
� . date.
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SUGGESTED INSTA ATION (Date ) FINAL INSTALLATION (Date )
,� (Road or Street) (Road or Street) ,
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` Person County Health Department
.y_ � Well Permit
DATE ISSUED: �� ��� '
OWNER: G
ADDRESS:
DRILLING CONTRACTOR:
NAME
ADDRESS
. vS �-�--.,
WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollution
Tota1 Depth: Ft. Yield: � GPM Static Water Lev 1 Ft.
Water Bearing Zones: D�pth��Ft. �Ft.
Casing: Depth: From U to Ft. Diameter: Inches
TYPE: Steel GalvaA�ized Steel
Sf Steel, does owner appkQyO Yes No
Weight: Thickness: `�aHeight Above Ground: Inches
Drive Shoe: Yes No
Were'Problems Encountered in Setti the Casing? Yes_No
If 'yes' qive reason:
Grout: Type: Neat San /G�ment Concrete
Annular Space Width L� Inches
Water in Annular Space: Yes No L�
Method: Pumped� Pr e Poured
Depth: From to�_Ft.
Materials Used: No. Bags Portland Cement Weight of
1 bag lbs.
If mixture (sand, �el, cuttings) - Ratio: to
ID Plates: Yes� No
4 x 4 slab Yes No
DRILLING LOG
De th
From To Forma ion Descri tion
� �
�
I HEREBY CERTZFY THAT THE ABOVE INFORMATION IS CORRECT AN THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE H GULATI SET RTH BY THE
PERSON COUNTY BOARD OF HEALTH. PE HREE RS.
of
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v
Date ]
Date
Sanitarian's Signature Date Completed
Sketch well location on reverse side.
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�e APPLICATION FOR SERV C S
_, _ . , _
Ser�ices Requesfecl. .
_ Improvements Permit (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing)
Improvements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Permit (Addition)
Repair/Replace existing Septic System
Permit for New Well
_ Replace Existing Well
1. Permit requested by:
�wner/prospective owner/agem
Address: � 0.V i c� Ti
7. Dimensions or Proposed Structure: �
Width: �,1� X a LI � �
� c>.1�1 Denth: Ce.ue-N'} S 1 ab 1 Ca
:ome Phone #: � 64 -�a �s C ����r. \
usiness Phone #: 3 6q - 1.3.�`7 � S�� �
. Name and address of current owner:
Description: Lot size: �� � 7 d
Tax Map#: r� 3 oC
Parcel#: 1 �
Townshin: 8 u S1r� �� �a r�
. Directions to property: State Road #& Road
tames, etc. �
-{-U S o.� C.�0.V � S
/' �„ n. � c� c� �- 2 N r 1
Number of occupants or people to be served:
. What type (if any, additions, expansions, or
;placement is anticipated to the structure or facility
iat this sewage disposal system is intended to serve?
9. Water su y�pe:
private' public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No ❑
If so, identify location:
10. Type of structure/facility: Proposed: DExisting: ❑
Type of dwelling:
House: ❑ Mobile Home: ❑ Business: ❑
Type of business:
Number of Employees:
�� Number of bedrooms:
Garbage Disposal? Yes ❑ No ❑
Basement? 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 PersOn COunty Health Department 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.
� J
Owner or Authorized Agent
- :
Permit Issued ❑ Signature
Permit Denied ❑
Plat Observed ❑
Date
FACTDItS•571'8 EVALlIAT10N ARPA 1 AREA 2;: AREi43 . >> AREA d;: .
_ _.. _ :
1. SIAPE(k) S S S_. ..�� $
PS PS PS PS
U U U U
2. SOIL TEXTURE (12-36 IN.) S S S S
(SANDY, LOAMY. CLAYEY. NOTE 2:I CLA� PS PS PS PS
U U U U
3. SOIL STRUCitJRE (12-36IY.) S S S S
(CLAYEY SOILS) PS PS PS PS
U U U U
4. SOIL DEPT}I (IN.) S S S S
PS PS PS PS
U U U U
5. RESTRICCIVEHOR(ZANS(IN.) S S S S
(IINPERVIOUS SiRATA, ROCK) PS PS PS PS
U U U U
6. SOII. DRAINAGFlGROUNDWA7ER S S S S
(EXTERNAL & INTERNAL) PS PS PS PS
U U U U
7. SOiL PERAIEABILTiY S S S S
(PERCOLOATION RA7E) PS PS PS PS
U U U U
R. AVAiLABLE SPACE S S S S
PS PS PS PS
U U U U
9. SI'fECLASSIFICAT[ON(SEEBELOW)
SOIL SERIES
S•SUITABLE PS-PROVLSIONALLY SUI'CABLE U•UNSUI'CABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.) C:VU�1iPRO�DOCSIAPPSEC.SMFINANCE.PC
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� O 1 �J 1
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map #� 3 2 Parcel # � Z
Zoning Township ���1.�-. �
Owner/Contractor ��-c� 7"���r=�,�, Date1D—/2--95
Location/Address�. �/L.��- �� � �� �r�t '
�.Y�- � � �,.. �/_ S.R.# �
Subdivision Name Lot#,
/ �►�
/ /�= �' �•► i�i �
— � ..
.
�� / �i
��'s�'�
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SEWAGE SYSTEM
�air Lot Area �Z • ' /t�u�,
) t/� Mobile Home `
iness # of Bedroo
As Installed
��
�
� %
,1
/ /
/ j
w �
Size of Tank I ��
Size of Pump Tank
Nitrification Line � '�- o �
Max Depth Trenches_
�
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 1�Q���^-� ��-- I.rJ,��2 �
Comments:
Date f�/ L-9S Installed by�.,az� Approved by GrJ ,1���
/ _ _ . , �.. � ,.
ell Permit Pai ❑
3ividual
Site .
Well
Semi-
Replac
led by
SYSTEM SPECIiFICATIONS
R uired Slab
ir Vent _
equired Well
Well Tag _,
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 fu[ure or that the water supply will remain potable. c:�amipro\permit.sam O1/95 rev.1.0