A32 165,QC�
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� �iPPLICATION FOR SERVICES
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, < 5er<vices Requested. ;: :
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Improvements Permrt. (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing)
mt�ovements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) ,_ Permit for New Well
Improvements Permit (Addition) ,_ Replace Existing Well
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' V�'ater Sample;to be Collected:, , '?
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_,..<: . _ :.< . _..::: _ . ._
_ Bacteria Chemical ._ Petroleum _ Pesticide
1. Permit requested by: . - 7. Dimensions or Proposed Structure:
�wn /prospective owner/agent� /�1�� � � Width:
e�l�l,-P��• s�o. /'�r/oc �o; v Depth:
ome Phone #�,
usiness Phone
_, Lead
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8. What type (if any, additions, expansions, or
' M—� p replacement is anticipated to the structure or facility
� ��.,� that this sewage disposal system is intended to serve?
. Name and dre�s of current owner: _
�,,d�,�.� ilr .f��e.� 1
. Property Description: Lot size: a� -
Tax Map#;
Parcel#: _
Township:
Sc`�
_�(
. Directions to property: State Road #& Road
ames,�tc.
��
Number of
or people to be served:
9. Water sup type:
private_ public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes L�' lo [j.
If so, identify location:����DA �- -� ��-�� �
�i1�7- d! �.t/-��i.r�'2Lc _
10. Type of structure/facility: Proposed: L�xisting: C3
Type of dwellin • "
House: obile Home: C� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: _ _
Garbage Disposal? Yes ❑ No 0
Basement? Yes ❑ No�7 If so, # of basement fixtures:
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 [he 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.
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Permit Issued ❑
PermitDenied ❑
Plat Observed ❑
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� Signature
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Date
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.� C:�.4AfiPRO�DOCSIAPPSEC.SD! flNANCE.PC
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T. A. Monk heirs
D.B.60-494
!fy that I s:� (�.•e a:e) the
�perty aho�-n and deacribed
�n'vcyed to e�e (us) by decd
County Regieter of DecCs
, FR�e and chaE F (�.•c)
>lan of subdivision Uith •
�nt, eatablSah th8 ❑in�c���
' dedi�cate all alleys� va1E:�9,
nd oEher open spacea [o public
oted. Purther I (�:e) her�eby ,
nd as shown hcrcon ia Within
vlation ju: icd2ctior� of
h Carolina . •
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Merle J. Brown
0. 8. 137 - 28g
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PERS�N COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPR4VEMENT PERNIIT
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
6as been issa�ed.
Tax Map #� 3 �
Zoning
Owner/Contractor � �� �
Location/Address �c� � 57 _ _ _-�
Parcet # � � �
Township t.� � K
�s1t� � Date �3' ��'2l�
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area j j/SatrN Size of Tank /�� 0
SFD ✓ Mobile Home Size of Pump Tank �}
Business # of Bedrooms 3 Nitrification Line yD0' �c 3�
Max Depth Trenches � � � � .
Permits may be voided if site i altered or inte de u e changed.
Well and Septic Layout by
Comments:
Date a- �- �j g Installed by ��-� ���..�•�- Approved by 6v.��eA ���.,,,,,,,
._J �.�Ga
ell Permit Paid
SYSTEM SPECIFICATIONS
dividual�_Semi-Public Required Slab f.�P ��
iblic Replacement Air Vent �
te Approved Required Well Log �- t��G v
ell Head Approved Well Tag v
•niitina Annrnverl . L( �
Comments:
Date �-�G- 9�'S Installed by �'ll��l5 i✓�« Approved by (�/,c;C.��-�•�,••.,,-�
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permi� 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 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:lamipro\permit.sam O1/95 rev.l.l
PL•'IiSUN COUid'I'Y 1.;NV:I:RONP,::N7'�til, I11.ALTII
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lJlil,l, I,UC
Date: S� � l �F�S 7
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Owner: —�s...`f_L�____�(� ��-
— -�s1z,-.__ -- -- ----- ------- SR#�
Location%Directions: _Clz�-� /;_i �yr�,� �___
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�ub'�vlsion N�u»e: -- --- .
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Drilling Contractor:.__ � �
. � t��a- n.�._ _-- � � - �--�. �; .� �
W1 I,I,_C_C)NS'I'RI1CT'1nN �
Distance from Nearest 1'roper�y Li�ic__�����_ lli:��ancc from Source of '
Pollution a � u,s ,
; ;,
Total.Dep.ch: ' v Fc. Yicld: ti;
_� _.:_ G1'M S tatic Water Level �F� �
Water B�earing Lones: Depth � � � [._%�a �. t. F[. � .��t. <.
Casing: Depth: From �-- yy �`�y
to '<
---� �t- .i�laltlCLl:I". 6 ` �I'1C�leS .y�
TYPE: Steel � Galv,inizccl Stecl � Y � "
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Z,f Steel, does owncr approv�:: Y�;;; N�� .. -�;
� Weight: ' / 4 r1 „1C1U1�.JJ, � J9r
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�'—"`�-7�'—' . . cigh['Abov.e Ground:-_ �t--�nches �. ��. _ ����
Drive Shoc: Ycs_____`�N� = - x
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Were Problems Encounterccl in Sctlinb t}ic Casing? Xes � No �� _.:.,
IC "yes" give reason: _;•
Grout: .T Neat - � T . � $`, , ��
YP�� S�Iicl/Cctnen[ �- Concrete ' ' ` �
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Annular. Spacc Wiel[li 3 Inchcs �"�''��
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Wa[er in .A,iulul�u' Sp.zcc: Y�:1_ --- No �- , Y1.:
Metho.d:' PumFx:c�� .-- I'r<<.tiurc � - �� . .. . .
I'ourcc] 3 �
llcpth: From ---- tv-----�� I��- � r �- .
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Ma[erials Usecl: No. F3ags Poctl�uid Ccmcnt j,i Wei�t of .l�bag_,�_lbs �`
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IFmixture (sand, gravc;l, cuttin��s) - Ratio: `~�- �k*i<j,t
II� Plate �J �O � � . . " ��'
s: Xes`-� No . .. �>5�=,
� 4 x 4 slab Yes -� ---------- `;
No_ ._-,-,
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Z HEREBX CERTIFY TH�1T T�-IE A,�30VL 1NF0 �' '�
RMATION IS CORRECT AND��THA� R
T�s WELL WAS CONSTRUCTED IN �,CCORDANCE WITH REGULATZONS =Sf M�., .
FORT�-I $Y�T�-iE P�RSON CnUN7��' I-II:AI_,TI-t �EPARTMENT. `� .,?
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p�/ //�/ �_ . ��"'nt�i
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Si�;,�aturc c�(� Coiltrrictor
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