A32 133- Pe�son, County Health Department
�Sewage System Improvements Permit
Date: �`�� 's Permit Void After 5 Years P rmit # C�"� �`� �
Owner: y' V r p .T� �, m SR# -�, _�
LOC8t10i1�D1I'eCilOIIS: , i /` � _ i" . `
Subdivision e: ' � � � Lot #
Lot Size: Type of Dwelling:
Water Supply: Private: �— Public: � Community:
Bedrooms: 3 Gazbage Disposal ' '
Basement Basement F' es '
INFORMATION CERTIFIED BY _ ' . .
Environmental Health Specialist: e.. er r
REPAIlt: REEVALUATION:
-------------------------
Size of Septic Tank: I�D gallons �Size of Pump Tank:
Nitrification Line: t-/(�,LY2
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks:
-------------------------
Date
BY_
Date
BY�
Contractor.
� Well should be 100 R fmm any sewer system
— Environmental Health Specialist
� 2�, 5 y
_ Environmental Health Specialist
�A'IT OF COMPLETION
Sewage System location, installation, and protection must meet state and local
regulations. Septic tank should be pumped out every 3 to 5 years and shall be maintained
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 Departrnent before any portion of the installation is covered and put into use. If
the site plans or intended use change this pernut is subject to revocation.
(G.S. 130 A-335F)
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
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Perso�t County Health Department �
� Well Permit . �
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Date:' '`!�' This i�eimit Void After 3 Y
ow�: �,,�r.;�.—�l, ,z �� I w. sRa /S?.S
LocaaoNDirecdons: -
Subdivision Name: ' t #
Drilling Contractor: C
wF�,L• CON�UCi'ION
Distance from Nearest Propaty Line Distance from Source of
Polludon
Total Depth: Ft Yeld: �GPM Static Water Levd Ft
Wata Bearing Zones: Depth F Ft Ft Ft
Casing: Depth: From ��� Diameter Inches
TYPE: Steel Galvaniud Steel ►�
If Steel. does owna approve}-�� No
WeighC Thiclmess: � He�ght Above Ground: Incha
Drive Shoe: Yes No
Were Problans F.ncoimtered in Setting the Casing? Yes ' No
If "yes" give nason:
Grout Typa ,Neat Su�I�d/iCement Concrete
Annular Spaa Width I C� Inches
Wata in Armular Space: Yes No
Method: A�mped Pressure Poiaed✓
Dep:.i: Frm;► —� to �_ Ft
Mataials Used: No. Bags Pottlaad Caneat Weight of 1 bag
lbs.
If mixture (sand. gravel, cuttings) - Ratio: to
ID Plates: Ya �� No
4 z 4 slab Yes �— No
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I HEREBY CER'TIFY THAT THE ABOVE WFORMATION IS CORRECT AND THAT �
THIS WELL WAS CONSTRUCTED W ACCORDANCE WITH REGULATIONS SET ;�
FORTH BY THE PERSON COUNTY H�TH DEPAkt'�,MENT. � �
Dau
Issued
Sanitarian's Signature Date Completod
Sketch well locatian on reverse side. '
Amount
Rereip
O
paid . 021 • �
t . 4� ' � d �
- ' � —
�'�–� /
Date
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W
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. permit requested by: . . Dimensions or Proposed Structure: I
owner/prospective owner/agent: � � � Width: 6�!
.�� ._ � � _ ' _ . r,P.,rh• �/v -
'� � l ��7//s 8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility .
// 4z oX a'nd �/�' �757�3 that this sewage disposal system is intended to serve?
ome Phone #: ��l`/�5�7
usiness Phone #: ,So�-3So4
Name and addre�s of current owner: 9. Water supply t}pe:
� �f��� � private �j . public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No [�.
If so, identify location:
Description: Lot size: 1.� � �—
Tax Map#: �t'. �S G
Parcel#:
Township: � � - �
Directions to property: Sta[e Road #& Road
ames,�tc.
l3/� ���
10. Type of structurelfacility: Proposed: DExisting: Q
Type of dwelling:
House: ❑ Mobile Home: d Business: ❑
Type of business:
Number of Employees: .
Number of bedrooms:
Garbage Disposal? Yes ❑ No �7
Basement? Yes ❑ NoL If so, # of basement fixtures:
6. Nut%ber of � cupants or people to�tie served:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES•
I hereby make application to the Pet'SOri COunty �Iealth 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 evenc I have not
delivered a survey plat of the property to-the Health Dept. wi�in 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become vo[d and all fees paid forfeited.
Z Signcc� Owner or Authorized Agent
�
�
4
permit Issued ❑ Signature Date
Y
permi[ Denied ❑
Plat Observed ❑ �
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9. SIiECLASSIF7G�T10N(SEEBELO�
SO1L SERIFS
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S-SNTAIILE PSPROYISIONALLYSULTAIII,E lt-tlNSUITADLE
RECOMMENDATIONS/COMMENTS: -
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, �ill
areas, wells, water bodies, slope patterns, etc.� C:V1M(PR0IDOCS�APPSEC.SA1 FWANCEPC
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PERSON COUNTY 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 2 Parcel # 13 3
Zoning Township ��;;.� y �-�,2,�
Owner/Contractor �, o� Date S-- �- q 2
Location/Address i<--� s [C Fr !-��ss __ R9_�____ .� M+�t o�.r
[E� T . � ' S.R.#
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICAT'IONS
Repair Lot Area �_� e� �- Size of Tank t x � s r�,.r � ioc� v G�a L
SFD ✓ Mobile Home Size of Pump Tank �-
Business # of Bedrooms__� Ntrification Line �X ��,-i,�,��,- cr��' xz
Max Depth Trenches -- -
Permits may be voided if site is altered or intended use
Well and Septic Layout by ��,1 i1i,�� �
_
Date ��,�T y 7 Installed by �i�,—��t � Approved by
Well Permit Paid ❑ WELL SYSTEM SPECIFICATIONS �k� g� �,v —
Individual Semi-Public Required Slab
Publ'c eplacement --, Air Vent
Site A roved Required Well g
Well Hea pp ved Well Tag
Grouting Ap ved
Comments:
Date Installed by Approved 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 conceaIed 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 future or tbat the water supply will remain potable.
c:\amipro\permit.sam 01/95 rev.l.l