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A32 120�-� �� r � Person County Health Department � Sewage System Improvements Permit Date• ' � is Permit Void After 5 Years �� Owner: ^ ' SR# __�_�c__�_ Location/Directions: r ' P �-�n,..t l'i/•- r � Subdivision Name: Lot # Lot Size: ��c� Type of Dwelling: _ Water Supply: Pnvate: Public: Community: `` Bedrooms: � Garbage Disposal � Basement Basement Fixtures INFORMA I� IED BY� /'��f f� �a -�,l' 5�1��: �� oaner or repmsenfaRve ` REPAIR: REEVALUATION: �� Size of Septic Tank: _�j�Q-- gallo�s Si � of Pump Tank: ---- Nilrificauon Line: _ _ /') Depth of Stone: 12 inches Max Dep[h of Trenches: Altemadve System: Conv. Pump LPP Pump Remarks: �----------- Date Well Approved: ��' vWell should be 100 f� from any sewer system BY Sanitarian Date S a Sy p oved: - BY Sanitarian E FI A F COMPLETION Contractor. ------- ----------------- '-3 � 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 create a public health hazard. Septic tank and'� nitrif'icadon 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 pemut is subject to revocation. � (G.S. 130 A-335F) C.J Location of sewage disposal sewage system sketched on back. � � (OVER) yV 0 I - '' Person County Health Department � Well Permit � Date:S- /.� D This Permit Void After 3 Years '� Owner a SR# � r�3 Location/Direcd s: � Subdivision Name: Lot # Drilling Contractor: F��-�, s 1,! ,� WELL CONSTRUCTION ►�d Distance fro e t Property Line� Distance from Source of �-�' Pollution �'�-f ; ; Total Depth: �}�c. Yield: ��GPM Static Water L.evel _�_�Ft. � Watez Bearing Zones: Depth �_ Ft F� Ft. FG Casing: Depth: From �_ to F� Diameter� Inchcs TYPE: Steel Galvanized Steel If Steel, d�wner appmve: Yes No Weigh4 � Thiclrness: Height Above Ground: Inches Drive Shce: Yes � No Were Problems Enco�mtered in Setting the Casing? Yes No � If "yes" give reaso : Grout: Type: Neat Sand/Cement Concrete Annular Space Width �_ Inches Watet in Armular Space• Yes No �� Method: Pumped Ptessure Poured L� Depth: From � co �._ F� Materi Used: o. Bags Pordand Cement � Weight of 1 bag lbs. If muture (sand, gravel, cuttings) - Ratio: �� to �__ ID Plates: Yes t� No 4 x 4 slab Yes � No I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCfED IN ACCORDANCE WITH REGULATIONS SET FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. ��. �,�'�1.� . G Y��9 Signanue of Contractor Date �/�.�., ��.A!t/ C P S- I S-9lc Sanitarians Signamrc Date Issued Sanitarians Signature Date Completed Sketch well location on reverse side. I� NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water � supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located �` at later date. Note location of water supplies on adjacent lots. (1) (2) '��■��e■��■��■�■��■■ ■■��■��■��■ ��►r��■ ■��■�.i��■ ■��■��N��■ ��■ ■��■�■ ��-■��■��o ■�� ■��.�.��■��■ ■��■ ■��s�� ■ �� ■�� ■�■��■ ■�� .�� n�■ ■��■_!��...��■��■ ■■ ��i�.....�� `�� / �/-3 � N � a w � a .� J PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION Ilv�ROVEMENT PERMIT B 1511 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_3z Parcel # I zv Zoning Township f3v,yyy FvTz,� Owner/Contractor R.4 Rsz Y MR � NEr� ��/ Date .z/zs/S 7 Location/Address . s-7 Ta .v,,,� v c t�-�►�� s �/�z ��.�t �/.4-� k � �v s S.R.# f/J � Subdivision Name � � Lot# SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area /, 0 3.4-� Size of Tank EX /ST/�/lr rv �� •4 c. SFD Mobile Home ✓ Size of Pump Tank Business # of Bedrooms�_ Nitrification Line E X,� T.,��r �� x.� � Max Depth Trenches Permits may be voided if site Well and Septic Layout by� Comments: �?,. �/4 � , .. .. Date� Well Perrr Individual_ Public Site Appro Well Head Grouting Comments: Date or intended use �->Hn�'rl�-7t� s� ri i�_ �, �si � ri � Installed by E,� � s; ,,� �r Approved by y.,.�./i G �__�� Paid ❑ WELL SYSTEM SPECIFICATdQNS Public IRequired Slab ;emen Air Vent � Log ell Installed by Approved by This report is based in paa-t on information provided the homeowner or his/her representative in the application submitted for this permit. The environmentel health specialist is not responsible for false or misleading information contained in the application. The environmental health specialist is also not responsible for concealed condi�ions on the property or for statements in this report that may have resulted from false or misleadiag 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 ,• � _ �_��_�� 0 a � � w U � a �Permit requested by: . wner/prospective owner �ddress: ��1� �c-w, i�.. ti o �P nn�lls ome Phone #: � �/o�' 3� `'/- /�OS" usiness Phone #:�i -s`5 9-. S z s S 7. Dimensions�or Proposed Structure: �,, ��,e.�1 Width: � � � _n ' TlPnrh• ••�� 8. What type (if any, additions, expansions, or replacement is anticipated to the structure or facility tha� this sewage disposal system is intended to serve? I /U°1J�- Name and address of cunent owner: 9. Water supply t}'pe: S G rn� private�..�. ,public❑ community ❑ spring ❑ Are any wells on adjoining property?Yes`.� No � If so, identify location: 3. Property Description: I,ot size: W � z Tax Map#:�� Z - Parcel#: � z v - � Township• 1� c.,.s {,.. �� - Directions to property: State Road #& Road ames,�tc. , � �- � �� r�. -�i� -� � �/r ��. i� �� . r�0 ,. �e _ .� _.i_.t ,.,� , ��/� �.�k.��< L��6� � l� f_ _ v rv �pe of structurelfacility: Proposed: �xisting: Q Type of dwelling: House:C3 Mobile Home: C�'Business: ❑ Type of business: Number of Employees: • � Number of bedrooms: __ 3______ Garbage Disposal? Yes ❑ No f�' Basement? Yes ❑ No� If so, # of basement fixtures: 6 Number of occupants or people to be served: . � --� CLEARLX STAKE ALL CORNERS OF THE PROPERTX AND THE CORNERS OF ALL � PROPOSED STRUCTURES. I hereby make application to the PexSOn COunty Health Department for a site evaluatioa f�on ahe o�e ite sewage disposal system for the above described property. I agree that the contents of this appl 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 Pecmit can b� 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 pcoperty to the Healch 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. ``o. c�°.a� — Signc� Owner or Authorized Agenl Signature Date � � � Permi� Issued ❑ � Permit Denied ❑ Plat Observed ❑ RECOMMENDATIONS/COMMENTS: --� � SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, ��» areas, wells, water bodies, slope patterns, etc., C:V�AtIPRO�DOCSV�PPSEC.S�4FIN�NCEPC C O 9 Y E O E Charlie Andrew Ookley N -08-36 •02� 16.40' 60'. � ' Cleve G. Moore 3 N O co 8M O � N R/�y R. Larry Rimmer D.B.137-299