A32 1430
�Site $valuation Application
. .
Fee Collected YES �
Pd ��� ��3q�3
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Date:
NO
APPLICATION FOR IMPROVEMENTS PERHIT
1. Permit requested by: owner/prospective owner: /r/i;�
�� gent:
Address: �„�--� ��� -� E' �� J`%/����+u�� ,
Home Phone ��: Zj2 .3d � � Business one ��:
2. Na e and address o current owner: r�� lt /(//V�i �
- X .� �y'_.___�_ .�� ST, 75� _ �c
3. Property Description: Lot size: � i�Cv-� S`
4. Tax map ��: Township: _ Y
Subdivision Name: Lot ��:
5. Direct�ons to propert�: State o d�� & Road /Na� es,
��% dl--S% Chir1�' ih � �i ���47au�� , �Y�/ �
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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:
C�
Q
10.
/ / /
Dimensions of Proposed Structure: Width: �� Depth: ��a
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?�
Water supply private? Y public? community? spring?
Other source? (Specify):
Are there any wells on adjoining property? If so, identify location:
11, Type of structure or facility: Proposed: Existing:
Type of dwelling: House: Mobile Home: � Business:
Type of business: Number of �mp, yees:
Number of bedrooms: Garbage Disposal? Yes No `
Basement? Yes No �If so, number of basement fixtures: '
12. 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 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. Permission is hereby granted to
enter the property for the evaluation. G.S. 130A-335(F)
v%!'�lG1Gc�G�G.� i�,c� G'n�— � � .
Signed Owner or Authorizeci Agent
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Permit Is:�u�d „ ,�
Permit Denied
Plat Observed
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7�ACTORS - SITE EVALUATION AREA 1 AREA 2 ARF.A 3 AREA 4
1. SLOPE (X)
. SOIL TEXT[TRE (12-36 i.n. )
(Saady, Ioamy, clayey,
Note 2:1 clay)
. SOIL STRUCTtTRE (12-36 in.
(Clayey soils)
4• SOIL DEPTH (in.)
�: RESTRICTIVE HORIZONS (in.)
(Zm�ervious Strata. rock)
. SOIL DRAIIIAGE/GROUNDW
(External & Internal)
. SOIL PERMEABILITY
(Percolation Rate)
$. OTHER (specify)
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9. SITE CLASSIFICATION � (� � �
(See below)� `1�
SOIL SERIES :
S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECOt�4fENDAT IONS / COZ4IEDITS : ,_
�'FTE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines. roads, streams, gullie� �
aet areas, fill areas, c�ells, water bodies, slope patterns, etc.)
d8166/1996 1�:13 5971799 PL�tt�IhlIhFa !�hlD ZOhJIhMa
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i'ERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PEP.MI�
Tax Map # /� 3� Parcel # 1��
Zoning Township 8 �s H Y ��K
Owner/Contractor �A R i nd �A /►�f a+? P o v�! Date _5 = i�- 4 y
Location/Address 157 5 To s z to t ���� c�rte�+��i-C �C� - r,n1Ti �3���tc �-�
r� onl T�� DY's �A2A�t �b S.R.# /�dl / �'�scnt cs .
ubdivisionName ���"�"" Lot# --- ��i� ��a az���
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SEWAGE S�YSTEM SPECIFICATIONS
Repair Lot P�rea ?Z�7 f!G Size of Tank �oo ��'ra �
SFD Mobil� Home � Size of Puma Tank �G/sa
Business # of B�dro�ms�3 Nitrification Line �oo ' x 3''
Max Depth Trenches ��7"-��''
Permit Void after 60 months. Permit V�id if not in compliance with zoning regulations.
Permits may be voided if srtF i te ed ar intended us�chan .
Well and Septic Layo�at by��� �� ..� ,
Comments: zv" - zy'� ��K T�ti1�N- /% ��
Gn! L�1�JT�v��
Date Installe3 by Appr�ved by
�A �D �VELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab
Public Replacement Air Vent �
Site Approved Required Well Lo�
Well Head Approved� Well Tag
Grouting Approved
Comments:
Date
Installed by
Approved by
s
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 Wormation co�ained in the applicatioa The environmental heatth specialist
is also not responsible for concealed conditions on the property or for statements in tlus repo�t that may have resulted Erom false or misleading
statements provided to him in the application. Neither Person Cou�y nor the environmental health specialist wacrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable: c:�amipro�petmitsam Ol/95 rev.1.0
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� PERSON COUNT� HEALTH I?EPARTMENT .�� � ��
�� WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # � �, Parcel #
Zoning Township �
Owner/Contractor ate �- � l�- �l_,5' �.-�
Location/Address ` _ - `i �1 /�fi ev,:��r�,.�
j�f ' o S.R.# E'rJ�+ � �,,,iC�
�ijl,q,'�y� �tz•ra' n Lot# � � �
6rti�!�=�P f �w� v
usiness
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2t��•.G+�,,.. - G�ovt
As Installed
SEWAGE SYSTEM SPECIFICATIONS
Lot Area �..2? �'uP Size of Tank 1'•
Mobile Home Size of Pump Tank KI
# of Bedrooms��. Nitrification Line �� �X 3'
Max Depth Trenches a � "
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered o' nd u ch ged.
Well and Septic Layout by
Comments:
Date Installed by Approved by,
Well Permit Paid WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab
Public Replacement Air Vent
Site Approved j,/ Required Well Log
Well Head Approved Well Tag
Grouting Approved
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 fot 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 condidons on the property or for statements in this report that may have resulted from false or
misleading statements provided to him in the applicntion. 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.1.0
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