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A32 144.�- ; � z ' �-- Person County Health Department � _ Se�y�age System Improvements Permit ,� Date:�`f. This Permit Void After 5 Years Permit # Z Owner: ��' Y�►� fz � S�cl; e 5,�,'0 �,:� _ SR# loo� Location/Directions: � , ' ' S✓��' � �',.? Subdivision Natne: � � � Lot #o Lot Size: �, ��rl�l•� - Type of Dwelling: !i'��i�:l� �-.� _� �.� Water Supply: Private: Public: ' Community: "'{ Bedrooms: 3 Garbage Dispos Basement Basement 'x � INFORMATION CERTIFIED BY � Environmental Health Specialist: ' er resen ' e REPAIR: REEVALUATI N: � ------------------------- Size of Sepac Tank: gallons Size of Pump Tank: Nitrification Line: (�(� � �� ° Depth of Stone: 12 inches Ma�c Depth of Trenches: Altemative S s[em: ,Cp nv. Pum PP� m� Remarks: y V n„ n p vn ��nTl ,�,`��3T_�,�� -------------------------- Date Well Appmved: Well should be 100 f� from any sewer system BY Environmental Health Specialist Date Se a st m proved: - '� BY Environmental Health pecialist _/ CERTIFTCATE OF COMPLETIO ,.� Contractor. .— �� " "� v � -------------------------- � � � 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 nisification line must be inspected and approved by a member of lhe Person Counry Health Depaztrnent before any portion of the installation is covered and put into use. If ' the site plans or intended use change�this pennif_is'subject to revocation. � (G.S.130 A-335F) _ Location of sewage disposal sewage system sketched on back. (OVER) � 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. + �r-� � . , (2) S�t�-'IDo! '�/(�( [ ��/ �� : U . - #-�rson County Health Department ' � Well Permit Date�l _. tl ` This Perm;t Void iter 5 Years Owner.��r�„��- � �%u��c S:� � 1��'r� SR# 1��- Location/Directions: Subdivision Name: Lot # Drilling Contractor: Fi!-$n s 1 WELL CONSTRUCTION Distance from Nearest Property Line_�ST G� Distance fmm Source of Pollution 0 � cc.S � Total Depth: Ft. Yield: GPM Static Water Level �TFt Water Bearing Zones: Depth Ft. Ft. Ft FG Casing: Depth: From�to��Ft. Diameter:�_Inches TYPE: Steel Galvanized Steel �--- If Steel, does owner approve: Yes�— No Weight:�_ Thickness:��Y Height Above Ground:� Inches Drive Shoe: Yes �No Were Problems Encountered in Setting the Casing? Yes No � If "yes" give reason: Grout: Type: Neat Sand/Cement ✓ Concrete Annular Space Width 3 Inches Water in Annular Space: Yes No �--- Method: Pumped Pressure Poured — Depth: From�to �-c� FG Materials Used: No. Bags Portland Cement�_ Weight of 1 bag��lbs. If mixture (sand, gravel, cuttings) - Ratio:�_ to / ID Plates: Yes � No 4 x 4 slab Yes_,� / No I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. /l /7 5'H • Sanitarian's Signature Date Completed Sketch well location on reverse side. NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water «tipplie�, etc. Note special problems existing on lot. Write in measurements in order that installations may be l.�';7ated'at later date. Note location of water supplies on adjacent lots. : �z� ��) � S'/%��'_ �(�C�� ,� ° �. ,, �� _�,o �� -��.-�� Permit requested by: . �wner/prospec[ive owner/agent: \ Address:_. Qt�Y'�� r 2� �� S,t�� Pe.S.� �tr' • �� . Fo•�r-r o�.Y , c� ,r tT ,. �.: ��. ,� C`Tv�o ve C`.�� w U � a I�.�, Y 1� M� 1l S ome Phone #: 3 6� -�� r73 usiness Phone #: - Name and address of cunenc owner: S.�M� 3. Proper[y Description: L.ot size: I 1�C-' W ¢ z Tax Map##: r4 3 � Parcel#: � �- 4 Township: .�5�`�. �� r �' _ Directions to property: State Road #& Road > .. 10.6 �. . �.. : . ..e- .- �,� C �.� , o �-- e o r��+ e- 7. Dimensions,or Proposed Structure: Width: �� Depth: ' ��- 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? 9. Water,su t}�pe: private public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes`.� No [� iIf so, identify location: �pe of structurelfacility: Proposed: �xisting: Q Type of dwelling: ,�` House:� Mobile Home: k�l�usiness: ❑ Type of business: Number of Employees:______ � J S, Number of bedrooms: ��,-.�/ Garbage Disposal? Yes ❑ � u ent fixtures: Basement? Yes❑ No � If so, # of bas e m 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 PeI'SOn COunty T:�ealth Department for a site evaluatioa f�on ahe o�eite 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 Permit can be issued, I must present a survey plat of the propercy 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. - � � ��Q- �� Signc� Owner or Authorized gent Permit Issued ❑ Signature Permit Denied ❑ Plat Observed ❑ Date a .z � a<K. ..� N ..;. k i.. � � ,� .}��y Y „„f .. .: ��AAF112 �":: r s 'v �;: :s.N1�RFJl3 sw., . ? .�.. RRE/�-4,.�� i-a,e>.-�<: YaZ`„t£,Lw.1.%i'+� s'... r f v4#_,.F.��CI'ORS-STTEEVAI.UA�70T7 s:3s, .. ::..r� .,,aN<.r .,. Y-f�.#:.i;�.t'.t�,a��,.`F e: 5 , al.::�.. . �YFA > .*s...::^'t�.. .: ... ., �,� >. . . l. SLOPE(%) S S S S PS PS � PS � U U U 2. SOILTIX7VRE(12-36IN.) S S S S (SANDY. LOAMY. CtAYEY. NOTE 2:1 �(aY) PS � � ps U U U U l. SOiLS7'RUCTURE(12•361N.1 S S S S (MYEY SORsI PS PS PS PS � U U U U S S S S �. SOfLDEP7}I(iN.) � � � ps U U U U S. RESTRICfIVENORRANS(IN.) S S S S (a1PFRYlOUS STRATA. ROCK) PS PS PS PS U U V � 6. SOfLDiWNAGFIGROVNDwATER S S S S (IXTFRNAI, dc WIFANALI PS PS PS PS U ' U U U S S S S 7. SOB.PE7tMFJ18ILfiY PS PS PS PS (P£RCOLOA770N RA7� � V U U b. AVA11J1Bl.ESPACE S S S S PS PS PS PS U U U �1 9. STiEClJ1SSIF1CAT10N(SEEBELOW') SOTL SE7t�E$ SSNTA6I.E PSPAOYLSIONALLYSUITADLE U-UNSViTAeLE RECOMMENDATIONS/COMMENTS: SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope patterns� C�C.� C:UFIIPRO�DOCSV�PPSEC.S�iftNANCE.PC � a w U � a NI B 1512 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMI'ROVEMENT PERMIT Not for waste water system construction. No permit(s) for Construction Location or Relocation Activity shatl be issued until Authorization for waste water system construction has been issued. Tax Map # /-� 3 Z Parcel # f yy Zot�it�g Township � ,, /Ca�� { Owner/Contractor ,,,�,�/�« Si►liP�s .r.�. _ Date_�/ /y7 Location/Address ,U�,�„ � r ,••,. « S ,,?n / T/G ��✓ ,w��N v_r _�� %� Subdivision Name Lot# S.R.# �oc�/ SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area �,¢L Size ofTank Ex�sTinr�- /o�►d �i� SFD Mobile Home ✓ Size of Pump Tank ------ Business # of Bedrooms_� Nitrification Line �j�isT�,� �r �1v� `� Max Depth Trenches Permits may be voided if site is altered or intended use chaqge Well and Septic Layout by � Comments: � c � ,,� 2 .t/o C�/.4N�rC %� �'��Ti c 5 �iSTE M Date c Installed by �x i� 1—i� �r Approved by ell Permit Paid ❑ ell Date WELL SYSTEM SPECIFICATIQNS �Public Well Slab Installed by Approved by Tlus report is based in part on information provided the homeowner or his/her representative in the application submitted for this perffiit. 'lChe 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 future or that the water supply will remain potable. c:\amipro\permit.sam Ol/95 rev.l.l H � ,og�c►�z 0 b �