A34 9The Distr�ct Health Department .
CASWELL - CHATHAM = LEE - PERSON COUNTIES� � �`
Water� Supply and, Sewage `Disposal `
- �1 PROVEMENTS �PERMIT • No.` �
'�.Da e ;--! , '� L ��'
Owner: �'���.r- . -
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Location•�— ' � + , _ _
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Contractor: � ���� �+� . . � - -
Water Supplp: Private __1-� Public
Sewage Disposal Faciliiies: No. bedrooms -�"`� Dishwasher, Disposal,
washing machin other �utomatic appliances ��—
Size of tank: '` j��l -� Nitrification i�nP•� l� S
f �-
Other disposal facility:
Water supply and sewage disposal facilities location, installation ahd
protection must meet state and local regulations;
5eptic tank should be pumped out every 3 to 5 years an3 shall be main-
tained by owner in such a manner as not to create a public health hazard.
_ Septic tank and nitrification line MUST BE INSPECTED AND AP- �
PROVEII BY A MEMBER OF THE DISTRICT I�E�L H DEPARTMENT �
STAFF BEFORE ANY PORTION OF THE 3�S A�.�LAT�ON IS COV-
ERED AND PUT INTO USE. �� r j , i'(
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Date a roved: Si rie � I'� �� { � �♦ �� T�� `•�!
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• We1L � G ��itarian`
Sewage' Disposal; ' Counter , • } - .
By: � - ` " ' signed .. . `-` . ; ':• '' .
(Owner or his representative)
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Cerlificale of Completion
Date Approved: �� B � , - ,�
anitarian , -
_ (OVER) �' - .
Location of well and sewag'e disposal facilities sketthed on back.`
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Improvements Permit (EstablishedlRecorded Lot) _
Improvements Pernut (Unrecorded Lot)
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Reinspection of Existing System (Loan Closing)
existing Septic System
Improvements Permit (Mobile Home Replace) v Permit for New Well
Improvements Permit (Addition) Replace Existing Well
Permit requested by:
rospective owne /agent:
,� .,� `
,, /,�� 3$ D
ome Phone #: 5 9y- l U/� _
usiness Phone #:
Name and address of cunent owner:
Tax Ma
Parcel#:
: Lot size:
������ � '
. Directions to property: State Road #& Road
ames, etc. � p
�u/�e GQc�,�i- �a l�c.�
Number of occupants or people to be served:
Dimensions or Proposed Structure:
idth:
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
Water supply type:
ivate �public ❑ community ❑ spring ❑
•e any wells on adjoining property?Yes ❑ No ❑
so, identify location:
10. Type of structure/facility: Proposed: �Existing: ❑
Type of dwelJing:
House: p1 Mobile Home: ❑ Business: ❑
Type of business:
Number of Employees:
Number of bedrooms:
Garbage Disposal? Yes ❑ No ❑
Basement? Yes ❑ No ❑ If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURE5.
I hereby make application to the PersOn COunty Health Depal'tment for a site 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. 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.
Signed Owner or Authorized Agent
l
Pern� Issued ❑ Signature Date
Permit Denied ❑ ' '
Plat Observed ❑
FACfORS-SITEEVALVA770N ARE.41 <: AREA2 : AREA3 AREA4 >:
,. _ _ . :
L SLOPE(%) S S S�� S
PS PS PS PS
U U U U
2. SOIL TEXNRE (12-36IN.) S S S S
(SANDY, LOM1Y, CLAYEY, NOIE 2:1 CLA� . PS PS PS PS
U U U U
3. SOIL STRUCRJRE (12-361N.) S S S S
(CLAYEY SOILS) PS PS PS PS
U U U U
4. SOIL DEPl1i (INJ S S S S
PS PS PS PS
U U U U
t. RESTRICi1VE HORIZONS (IN.) S S S S
(IMPERVIOUSS7RATA,ROCK) PS � PS PS PS
U U U U
6. SOQ. DRAINAGE/GROUNDWA7ER S S S S
(EXTERNAL & QTfERNAL) PS PS PS PS
O D U U
7. SOIL PERA7EABILITY 5 S S S
(PERCOLOATION RATE) PS PS PS PS
U U U U
R. AVAILAflLESPACE S S S S
PS PS PS PS
U U U U
9. SI'fECLASSIFICATION(SEEBELOW)
SOIL SERIES
S-SUITABLE PS-PROVISIONALLY SUI'CA6LE U•UIYSUTTABLE
RECOMMENDATIONS/COMMENTS:
STTE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.) C:�AMiPRO�DOCS�APPSEC.SMFINANCE.PC
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PERSON COUNT HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT PERNIIT
Tax Map # Parcel #
Zoning __ Township
Owner/Contractor
Location/Address
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Lot#
Date /� --
A 0!�56 �
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Layout . As Installed
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3 SEWAGE SYSTEM SPECIFICATIONS
;
Repair Lot Area Size of Tank _
SFD Mobile Home Size of Pump Tank
Business # of Bedrooms Nitrification Line
_ Max Depth Trenches
Permit Void after 60 months
Permits may be voided if s
Well and t by
Comments:
. Permit Void if not in compliance with zoning regulations.
Date Installed by Approved by,
� , , � va -� WELL SYSTEM SPECIFICATIONS
Individual 1/ Semi-Public Required Slab
Public Replacement Air Vent
Site Approved 1� Required Well Lo� _
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 for this permit The
environmental health specialist is not responsible for false or misleading infortnation contained in the application The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in tlus 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 ihat the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:\amipro�pemutsam O1/95 rev 1.0
OFiIGINAL
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PI:RSON CQUN7'Y ENi�IRONMENTAi. H�Ai,TH �, :: �
WELL LOG
Date: �� Q5 ' �
Owner: � � � �' � S�2#
Location/Directions: � �� . �
Subdivision �Name: � Lot #
Drilling Contractor:
� WELI, CONSTRUCTION -
Distance from Nearest Properry Line Distance from Source of
Pollution . � �
Total.D.ep.th:� Ft. Yield: �� GPM Static Water Level Ft.
Water Bearing Zones: D.epth______,_F�; F� � F���t. _
Casing: Depth: From �7 .to `�(-! Ft. Diameter: (0'l4 Inches
T �'PE: Sie�l � �alvanized S.e�1 ��S �
If Steel, does owner approve: Yes No �
" Weight: � Thickness: .• i 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/�ement Coricrete �
, Annular: Space Width � z Iinches �
f- .
Water in Annular Space: Yes � No ;� �
�Method: Pumped � Pressure Poured � ES
Depth: From 8 to 20 F� .
Materials Used: No. Bags Portland Cement Weig,Yit of .l�bag_lbs.
If mixtuie (sand; gravel; cuttings) - Ratio: to
ID Plates: Yes � No � � � �� �
� 4 x 4 slab Yes ✓ No
I HEREBY CERTIFY THAT THE ABOVE INFORMA'I70N IS CORRECT AND THAT
THIS WE�.L WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY•��E PERSON COUNTY HEALTH DEPARTMENT. � �
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� Signature of Contr tor Date
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