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A32 122� . ��erson County Health D'epartment Sewage System Improvements Permit Date• ��'This Permit Void ter 5 Years Permit # � � Owner: _�. �E SR# 1 ��%C,,.t itratinn/f)irrrtinnc• �_...n r_�" W Altec �brC � � ��C :..�0 r i i> V' ' F • � a-% h CrtJ � Su ivision Name: Lot # �L� Lot Size: Type of elling: Water Supply: Private: — � P�: '' �Bedrooms: 3 Garbage Disposal Basement Basement Fixtures INFORMATIO�? BY ' � c,,�.,` l-- Sanitarian: �� owner or tep[esa�tative REPAIR: REEVALUATION: ------------------------- Size of Septic Tank: �Q� gallons Size of Pump Tank: Nitrification Line: ,3 . -��O �'i.3 ' Depth of Stone: 12 inches Max Depth of Trenches: Altemative System: Conv. Pump LPP Pump Remazks: ------------------------- Date Well App �� Well should be 100 ft� from any sewer system BY Sanitarian IY►te rov - ' BY Sanitarian TIFT ATE F COMPLETION Contr�tor. ,_ _ ------------------------- Sewage System location, installation, and protection must meet state and local regulations. Septic tanlc should be pumped out every 3 to 5 years and shall be maintaine� by owner in such manner as not to create a public health hazard. Septic tank and nitrification line must be inspected and approved by a member of the Person County Health Deparmient before any portion of the installation is covered and put into use. If the site plans ar intended use change this permit is subject to revocation. (G.S. 130 A-335F) . L.ocatibn of sewage disposal sewage system sketched on bxk. (OVER) r ��.,; - � . 'Person County Heaith Department � Well Permit � Date: -�� is Pe it oid After 3 Years Ovmer: � � SR# �K � Location/Directions: ' �- 0 '�1 }' � ' C S s � �"' �-%� �N � (✓l�rLs� Subdivision Name: Lot # Drilling Contractor: L�d�-�s (�1 � /� C� WELL CONSTRUCi'ION ►� Distance from Nearest Property Line�rd,t Distance from Source of �' Polluaon /D d �4 /u, s � Total Depth: �Ft reld: GPM Static Water Level�,,�� FG � Water Bearing Zones: Depth Ft. �',,� Ft. /�,Z Et. Ft•.` Casing: Depth: From _� to ..,�� FG Diameter: � Inches TYPE: Steel � Galvanized Steel v If Steel, does owner approve: Yes No Weight:1� Thiclme�s: � eight Above Groimd: � Inches Drive Shce: Yes �� No Were Problems Encountered in Settin the Casin � Yes No � Grout B 8• If "yes" give reason: Type: Neat Sand/Cement Concrete Annular Space Width 3 Inches Water in Armular Space: Yes No � Method Pumped Pressure Poised [_... Depth: From d to � a Ft Materials Used: No. Bags Portland Cement � Weight of 1 bag � Ibs. If mixture (sand, �avel, cuttings) - Ratio: _� to �_ ID Plates: Yes �� No 4 z 4 slab Yes �— No I HEREBY CER'fIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WiTH REGULATIONS SET FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. Date � s/�/� Date Issued Sanitarians Signature Date Completed Sketch well location on reverse side. � � a � � NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water � supplies, etc. Note speciai 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. � 0 (1) (2) ■��%i�7��s� ��■ ■��rni■i�\�� ■��ii%��1�� 5��■ ■��r��l1�.!'!� ■ ��N��■■ ■��.:�:��i�� ■ ��v��■ ■��■�Ilifl�o�� ■��O ■��■ ■■ ��■��Si�]r�� ■ �� ■■ ■■.��■■��■■■■■� ■■■.■■■■■■■.■ ■■��^��■� �1��■��.■■■■■■■■■.■■ ■�,,�\-�I.I��■��' �■■■.■■.■...■ ■�� i� `�� ■��ns■ ■■��►��«*��■�� ■■ W�■ ` ' � H O � �� a� �°° ' h . gr ►-� � `�`: �C� � � °2 APPLiCATION FOR SERVICES ;. Ser"vices Re.guested Improvements Permit (EstablishedlRecorded L.ot) _ Reinspection of Existing System (Loan Closing) _ ImpFovements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System 1 provements Permit (Mobile Home Replace) _ Permit for New Well Improvements Permit (Addition) _ Replace Existing Well "' Water Sainple io. be Collecte� . :. ; . . _ .. ,. : _ ...: _ Bacteria _ Chemical _ Petroleum ._ Pesticide _ Lead l. Permit requested by: . 7. Dimensions or Proposed Structure: owner/prospective owner/a ent:�� . f a��-�,,� , I,' 1 � Width: � a �p o•�� l e ��°`-� ''" Depth: a 8 ddress: 7J ��e5s oQd - ur /��s ��• a �s'� 8. What type (if any, additions, expansions, or � replacement is anticipated to the structure or facility W that this sewage disposal system is intended to serve? � Home Phone #: �310 �-a ��'`� d usiness Phone #: - a 2. Name and address of current owner: 9. Water supply t}�pe: � � o� M� private�(. public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No p. If so, identify location: � ¢ X H W ¢ z , Property Description: Lot size: �. 3% , Tax Map#: � � � Parcel#: � z 2 Township: �u=S�i.N _ FDrlL _ . Directions to property: State Road #& Road ames,�tc. �Nrc/le i ��ro�C • �55 urd 10. Type of structure/facility: Proposed: �xisting: Q Type of dwelling: House: ❑ Mobile Home: I�Business: ❑ Type of business: Number of Employees: I�lumber of bedrooms: � Garbage Disposal? Yes No Basement? Yes ❑ No If so, # of basement fixtures: 6 Number of occupants or people to be served• ,�._� --� 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. Owner or Au�horized Agent Perrnit Issued � Signature Permit Denied � Plat Observec�❑ --�' Date �• . <::; .. Q: �ncroRs-sTre Evra.vano2�� ; . . i ., : A�s ), '> , ni�x z . . . ' ax�A 3 ;:: nx� a, ,_ _ _._ _ .: . 1. S�OPE (�) S , S S S PS ' PS PS PS U U U U 2. SOIL 7'EX7VRE (12•36 IN.) S S S - S (SANDY, LOAMY. CLAYEY. NOTE 2:1 CU.1� PS PS PS PS U U U U 3. 501L ST7tUCTURE (i2•161N.) S S S S (MYEY SOIL.S) PS PS PS PS U U U V 4. SOIL DEP7'F1(IN.) 5 S S S PS PS PS PS u u u u 3. RES7RJCTIVEHORI7ANS(IN.) S S S S (IMPERVIOUS S7RATA. ROCK) PS PS PS PS U U U U 6. SOiLDRA]NAG&GROUNDWATER S S S S (FJCTERNAL R TN7'ERNAL) PS PS PS PS u u u v 7. SOILPERMFA81LTfY S S S S (PERCOLOATION RAT� PS PS PS PS U U U U 8. AVAII,ABLESPACE S • S S S PS PS PS PS 2 U U U U 9. SITECLASSiF1CAT10N(SEEBELOVI� � SOIL SERIES S-SUITAIILE PS-PROVISIONALLY SUTTA6LE U•UNSUITADLE RECOMMENDATIONS/COMMENTS: SITE CLASSIFICATION DIAGRA.M (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope patterns� etC.� C:�ADIIPRO�DOCSAPPSEC.SMFWANCE.PC � (� 3 ,.. -� � � � � � '4 � � 1190 � � � a w U � a � M � PERSON C�UNTY HEALTH DEPARTMENT ` WELL AND SEWAGE SITE, LOCATION IlVIl'ROVEMENT PERMIT � 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 3 Z Parcel # 1 Z Z Zoning Township ,r3✓sy y Fv�,� • Owner/Contractor kA T� �/ 8 LAM�B� L[_ Date 8-o �- yL Location/Address ,y„ R o�� ,.•� � c cs Q c� r/� e,.i 4 � c.ss z t� % y �� E o�v t� FT S.R.# � S"1 S Subdivision Name Lot# SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area 3, ,3 -? ,4c- Size of Tank Ex � s�-. N� ivo o�.a� SFD Mobile Home ✓ Size of Pump Tank ,.iiA Business # of Bedrooms 3 Nitrification Line C x, s s�,.� � 3So � X�� Max Depth Trenches Permits may be voided if site is altered or intended use Well and Septic Layout by �� / � Comments: �?� Pc � �/o G�a N�� T� s EP i i c s Ys .—� �-�! _ , Date 9-�.-9� Installed by Fx � s r...r �T Approved by �,�,,,�,Q L — ell Permit Paid ❑ WELL SYSTEM SPECIFICATIONS iividual Semi-Public Required Slab � blic Replacement�� Air Vent ell Head Date Required Well Log Well Tag � Installed by Approved by cXiST�� !� 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 nealth specialist warrants that the septic tank system will continue to function satisfactorily ia the future or that the water supply will remain potable. c:\amipro\permit.sam O1/95 rev.l.l �