A32 187. ..���sU1��
S�te.Evaluation Application
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Fee Collected YES
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1. Permit requested by:
Address: �� . �
Home Phone �� : 3 E
NO
� �Date: � 3-1 jJ=� �' •
APPLICATION FOR IMPROVII�SENTS PIItHIT
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owner/prospective owner: (�i���
agent:
Y3aX I8''C� �OXbO►"U �'
q 0 t7l.� Business Phone� �r: _
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2. Name and address of current owner: ���
3. Property Description: Lot size: �'{" GCYeS
4. Tax map 4�: Township:
Subdivision Name:
5. Directions to property: State Road �� & Road-Names, etc.
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Lot ��:
6. Permit requested for: New Installation: � Repair: . �
Additional Renovation re-using present system: _
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7. Number of occupants or people to be served: `
8. Dimensions of Proposed Structure: Width: � Depth:
9. 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?
10. Water supply private? � 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 Employees:
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)
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�� '�" Signed Owner or uthorizeci Agent \
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Permit IsSued � � '
Permit Denied`
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)?ACTORS - SITE EVALUATION AREA 1 AREA 2 ARF.A 3 AREA 4
S S S S
1. SLOPE (X) PS S S
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2. SOIL TEXTURE (i2-36 in.) S S S S.
(SandS , Ioamy, clayey, P � ; / � PS � � � PS � , /C, PS�- fG�,%
Note 2:1 clay) U U � �
3. SOIL STRUCTURE (12-36 in.) S S
(Clayey soils) PS PS PS PS
U U U �
� S �� �7 S �-
4. SOIL DEPTH (i.n. ) S_, ���% �r� PS G�`�% �� P ��,,,, 7,� PS � 7
U �-- � � U ��.- <,2 �%' U `Z y �� �
5. RESTRICTIVE HORIZONS (in.) S /�%�
(Im{�ervious Strata, rock) PS �% �� PS ��� PS �� PS ���1"<
U/�' �` �i U �' U C� U �� �
6. SOIL DRAI2IAGE/GROUNDWATER S S S S
(bcternal & Internal) PS � PS �
U ' U U � U
7. SOIL PERMFABILITY � 5
(Percolation Rate) PS PS PS PS
U U U U
S S S S
$. OTHER (specify) PS PS PS PS °
U U U U
9. SITE CLASSIFICATION
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable _
R ECOt41EtIDATZONS / COI R iIIdTS :
S1TE CLASSIFICATION DIAGRAM (Includes Soil areas, property lines, roads, streams, gullies,
aet areas. fill areas, aells, water bodies, sZope patterns, etc.)
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= • PERSON COUNTY HEALTH�'DE�'ARTIV�ENT
WELL AND SEWAGE SITE, LOCATION IlVIl'RO MENT PEP.1b�T
Tax Map # A 3 02 Parcel # ���
Zoning Township `�us %u Fo� K
Owner/Contractor t,U r! (iQm t Conn��i.�11P(' Date_� �
Location/Address I 57 T� rct N�.rd !e M i I It� ?'��- br� 5���
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Lot#
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SEWAGE SYSTEM
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'ECIFICATIONS
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Repair Lot Area �/1Cr� Size of Tank /OOb
SFD Mobile Home ✓ Size of Pump Tank —..� -
Business # of Bedrooms 3 Nitrification Line �iLb' �C 3`
Max Depth Trenches �o �n
�� Pernut Void after 60 months. Pernut Void if not in compliance with zoning regulations.
� Permits may be voided if site is altered r int ded use c
� Well and Septic Layout by _
� � omments• `�L�JSi r411 aN �'^„-�^��� a� �%h r�n N;il as PosSiblP.
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Contac.,+ B�`�r�vJ Ft4�►l`�,os
Date 7, � 8- 9S Installed by�
- aaoy nr;o to �nU S'tte bis�u�6nnce �o
$.��. Approved by ct�.,�a� ,J�.�.,n� �fern,��ne i-�
c,�n�p cc�n �
`we.1� Na�t c�� c� WELL SYSTEM SPECIFICATIONS ��a'���
Individual ✓ Semi-PuUlic.
Public Replacement
Site Approved t�
Well Head Approved ✓
Grouting Approv�d
Comments:
Date
�n�;s T�._.. ._ ..___ ... ,._. _.. .._----------- �- - - -
envirorunental health specialist is not responsible for false or misieading information contained in the application The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in Uus report that may have resulted from false or misleading
statements provided to him in the application Neither Ferson County nor the environmental health specialist warrants that the septic tank system will
continue to fundion satisfactorily in the future or that the water supply will remain potable. c:�amipro�pemut.sam O1/95 rev.1.0
Required Slab ✓'
Air Vent �
Required Well Lo� ,,�
Well Tag
ORIGINAL
. . . I�I•:It�;��N �:�i�IN'I'Y I�.N�''�UNMLN�fAL III�:AI,'lll + � '
I�ate:
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W�LL LOG
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Subdivision �Name: � Lot #
Drilling Contractor�
� WELL CONSTRUCT'ION - .
Distance from Nearest Property Line Distance frd�n�Source of
Pollution_ . � n �
Total Dcp.ch: Ft. Yicld: 1 GPM Static Watcr Lcvel Ft.
Water Bearing Zones: D.ep Ft.�..._Fc. F� ��
Casin : De th: � From�to Ft. Diameter: Inches
g P
TYPE- Steel � Galvanized Steel �ES
• Yf Steel, does owner approve: Yes No
' Weight:_ `I'hickness: .• 1 Height;Above Gr�un�: Inches
Drive Shoe: Yes No _ . �
. Were Problems Encountered in Setting the Casing? Yes_. No
If "ycs" givc rcason:
Grout: Type: Neat Sand/�ement '� Coricrete .
, Annular:Space Width 7nches � �:
Water in Annular Space: Yes.,__._._ No ; �
�Method: Pumped � Pressure_ Poured �i ES
Depth: From �—to ��. �
Materials Used: No. $ags Portland Cement_ 1�leight of 1�bag_.lbs.
Zf mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes; No_ � '� �
� 4 x 4 slab Yes ✓ No
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I HEREBY CERTIFY THAT THE ABOVE TNFORMA'IZON IS CORRECT' AND THAT ;,,
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WiTH REGULATIONS SET
�ORTH BY•THE PERSON COUNTY HEALTH DEPARTME�I"I'. �
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