A34 10� F'�rson County Health Department
Sewage System Improvements Permit
Date:� �- �o - This Pe it VJid After 5 Years Permit #
Owner: / h � SR# �3Z Z
Location/Directions: �� i Il r� �� y° <
Subdivision N e: Lot #
Lot Size: ���('�('��,L Type of Dwelling:
Water Supply: Private: —� Public: Community:
Bedrooms: Garbage Disposal
Basement Basement Fixtures r
INFORMATTON CERTIFIED BY
Environmental Health Specialis : n r o T ,ta,ci/��e
REPAIR: REE AL ATIO : / V�-�
Size of Septic Tank: IQ D� gallons Size of Pump Tank:
Nitrificadon Line:
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remazks: _ --- - ---
-------------------------
Date Well Appmved: Well should be 100 f� from any sewer system
BY Environmental Heal[h Specialist
Date Sewage System Approved:
BY Environmental Heal[h Specialist
CERTIFICATE OF COMPLETION
Contractor:
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 snch manner as not to create a public health hazard. Septic tank and
nitification line must be inspected and approved by.a member of the Person County
Health Department before any portion of the installation is covered and put into use. If
the site plans or intended use change this pemut is subject w 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'nstallations may be located
at later date. Note location of water supplies on adjacent lots. �,� '�
� . , �, . , ,� �r. ._. ���� Yo� , , , _ �� �
5 r�t- r�3 2 z
�
S�
Site Ev�luation Application Date: �U'" � �r�
� � /
Fee Col�ected YES v 2d0
p� {O� ,Ot�
r ��" ��� APPLICATTOId FOR IMPROVEMENTS PEEiHIT
�� �q �� - ----
1.
,
2.
r
Permit requested by: owner �rospectiv�owner: .���
agent`:�
Address: (�'j�9-lC ���Z�J� ...��2 /.�,3`i' �
Home Phone 4� : � y' -r-I � c/c�� �/ Bus iness Phone ii :
Name and address of current owner: ��, �, ��'�,� �
T'-� e �.-L� !c.
3. Property Description: L�t size: � l O�G���r'�
4. Tax map ��: ' �-� `t�' � � Tawnship: �%o �� � �p
Subdivision Name:
5. Directions to property: State Road �� & Road Names, etc.
i.5 c_ J�"_n a �' :� t wl n. Vt� Q �U �.� N�R2 rC- .
�
�
�
J'��
I ��
i �
�.
�-/✓
��i����v�
S�n,- .C49� d�//3
Lot 4�:
6. Permit requested for: New Installation: � Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served:
8. Dimensions of Proposed Structure: Width: Depth:
z
9. What type (if any) additions, expansions, or replacement is anticipated to the struc-i
ture or facility that this sewage disposal system is intended to serve?
10. Water supply private? � public? _
Other source? (Specify):
Are there any wells on adjoining property?
11,
community? spring?
If so, identify location:
Type of structure or facility: �roposed: � Existing:
Type of dwelling: House: � Mobile Home: Business: _
Type of business: Number of Employees:
Number of bedrooms: Garbage Disposal? Yes ro �
Basement? Yes No If so, number of basement fixtures:
�
x
H
w
�
12. Clearly stake all. corners of the property and the corners of all proposed structures.l
i
I hereby make application to the Person County Health Department for a site
evaluation or existing system evaluata.on 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)
� �i �/�('9'7iLC'e-� � � .
Signed Owner or Authorized Agent
r
0
rt
m
�d
�
H
�
�•
r+
�
� � lS iv�C
Permit Issued
Permit Denied
Plat Observed
� �, S�r� Sci��,��is��
� /
� �
..� Y ��
�
Sey �
a�s°�
�
�
i?ACTORS - SITE EVALUATION AREA 1 AREA 2 AREA 3 AREA 4
1. SLOPE (X)
2. SGIL TEXTURE (i2-36 in.)
(Sandy, Ioamy, clayey,
Note 2:1 clay)
? SOIL STRUCTIJR.E (12-36 in.
(Clayey soils)
4• SOIL DEPTii (i.n. )-I " S%wl1 k
5. RESTRICTIVE HORIZONS (in.)
(Im{�ervious Strata� rock)
6. SOIL DRAIHAGE/GROUNDWATER
(�cternal & Internal)
. SOIL PERMEABILITY
(Percolation Rate)
$. OTHER (specify)
S
S
c;� �,, ✓�' .�
S
� S � (�
S C�SS ���,
PS 3 � ��
S
�Nb1.�
U
S n% �o itiw`t7�
�
S
PS
U
S
PS
U
S
PS
U
S
PS
j]
$
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
$
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
�T
S
PS
U
S
p$
U
$
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
9. SITE CLASSIFICATION � �
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECOr44ENDATIONS / COt�RiF�ITS :
S�TE CLASSIFICATION JLAGRAH (Include: Soil areas, property lines, roads, streams, gullies,
Wet areas, fill areas. wells, water bodies, slope patterns, etc.)