A34 97' Si,�e E�aluation Application Date: �1 -oZ'7-9�
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�Fee' �;o1lEctecj YES. � NO
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Y t��a'n ' PPLICATION FOR IMPROVEMENTS PERHIT
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1. Permit requested by: owner/prospective owner: �
agent:
Address: �� � �f�� l� � C- � oC0 �i
Home Phone ��: S9 �� -`-� 9� � Business Phone ��:
2. Name and address of current owner: ���U! � �
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3. Property Description: Lot size: ,� �CC c S
4. Tax map ��: 3�i 3 3 Township : �L W o�s � a � e
Subdivision Name: Lot �i�:
5. Directions�to property• State Road �� & Road Names, etc. S �Z
\� � � �1, C . � I � '� �-,l� C� vL� ,� �� :� _ _J_ ��
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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:
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?
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10. Water supply private? 1/ public? community? spring? �
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Other source? (Specify): "
Are there any wells on adjoining property? If so, identify location: �
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11, Type of structure or facility: roposed: Existing: �^,
Type of dwelling: House: Mobile Home: Business: �
Type of business: Number of Employees:
Number of bedrooms: � 3 Garbage Disposal? Yes To
Basement? Yes No If so, number of basement fixtures:
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12, Clearly stake all corners of the property and the corners of all proposed structures. �
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I hereby make application to the Person County Health Department for a site ,�'y
evaluation or existing system evaluation for the on-site sewage disposal system for Y,
the above described property. I agree that the contents of this application are true rt
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. R
Permits are valid for 60 months from date of issue. Permission is hereby granted to fi
enter the property for the evaluation. G.S. 130A-335(F) '
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Signed Owner horize� Agent
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�mprovemerits Permit (EstablishedlRecorded Lot)
Improvements Permit (Unrecorded Lot) -
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
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Reinspection of Existing System (Loan Closing)
Repair/Replace existing Septic System
✓ Permit for New Well
_ Replace Existing Well
..: ,, . _ ..__ _
B acteria Chemical Petroleum -_ __ _ Pesticide ,_ Lead
1. Permit requested by: 7. Dimensions or Proposed Structure:
owner/prospective owner/agent: �����-� �±�'� !-�' �=7 Width: �y �
Address: 1�,4� �t Po ;� d� x�i�+" ��i Depth: l�o'
��r�� �e ��� � �� � ��� � ��� `f 1 g, What type (if any, additions, expansions, or
replacement is anticipated to the structure.or facility
that this sewage disposal system is intended to serve?
Home Phone #: �a� " ���� ` `�S� �
�fBusiness Phone #: �-�� - �� a- ��1
Name and address of cunent owner:
: Lot size: S F�.re's
Tax Map#: � 3`�
Parcel#: `� '7
Township: w oc� c� s c,1►�:1 �
Directions to property: State Road #& Road
mes, etc. ' t`c��,�: �.� fs� �3�tn2 )
: .�. f� C n�' t""� ,._.1.. lY�n�L...�-N�i�f
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Number of occupants or
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to be served: a
9. Water supply type: ,
private � public ❑ community ❑ spring ❑
Are any wells on �adjoining property?Yes ❑ No �
If so, identify location:
10. Type of structure/facility: Proposed: xisting: ❑�
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, # 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 Depai'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.
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Owner or Authorized Agent
rmft Issu�,^.i ❑ Si natuce �+�u �d/7,�e%�I ' s"3� `%� Date
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Permit Denied
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<; FAC1'C1RS-Si'i`E EVAi.VAT?ON ° `
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z _ARP� t . ;i: . ARFA 2. . ;: ` ",4REA'3 "AREA d "
l. SIAPE (%) S S S S
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2. SOn. TE?:IURE (12-36 IN.) S S S S
(SANDY, LOAMY. CLAYEY. NOTE 2:1 CLAY) PS PS PS
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3. SOIL STRUCfURE (12-36 IN.) S � S ' S S
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S. RESTRICI7V E HORIZONS (IN.) S J� S ' . S � S
pMPERVIOUS STRATA. ROCK) PS PS PS PS
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6. SOII. DRAINAG&GROUNDWA'IER S S S S
IEXl'ERNAL& WiERNAI.) � PS PS � PS PS
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7. SOIL PERMEABILTIY S S S S
(PERCOLOATION RATE) P PS PS PS
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8. AVAILABLE SPACE S S S S
PS PS PS PS
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9. SiTECLASSIFlCATION(SEEBELOW)
SOIL SER►ES
S-SUITABLE PS-PROVLSIONALLYSUifADLE U•UNSUITABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.� C:WNIPRO�DOCS\APPSEC.SMi7NANCE.PC
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PERSON COUNTY HEALTH DEPARTMENT
B 1231
• '. � WELL AND SEWAGE SITE, LOCATION IlV�'ROVEMENT PERMIT """"""
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' � Not for waste w�ter system construction. No permit(s) for Construction Location or �
Relocation Activity shall be issued until Authorization for waste water system constr:���ion
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Tax Map # � .3 � Parcel #
Zoning Township s c/
Owner/Contractor `1 e n n��e V�— •,� � P Date s� «�j (��
Location/Address SfL� 13� � S�� 1�'��7 � s�� /3�"S �-o j��- �:,
� e� k o� Sn �- 13 3� S.R.# 1331�
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area S. Q ac+-zs � Size of Tank %[�(�( �Y� �r I
SFD Mobile Home��" ��.Se'"` Size of Pump Tank � ., �
Business # of Bedrooms� Nitrification Line / `
Max Depth Trenches "
Permits may be voided if site is altered
Well and Septic Layout by /
Comments:
Date
ell I�ermit Paid
Installed by.
-16-�t�
use changed.
Approved by
WELL SYSTEM SPECIFICATIONS
dividual �/ Semi-Public
�blic Re cement
te Approved �
ell Head Approved _
-outing .Approved �
Comments:
Required Slab �/
Air Vent
Required Well Log
Well Tag i /
Date Installed by ✓f� e Approved by
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D Y�i ih �g� � �,��s
f h S� ��:�i d
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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 respunsible for false or misleading information
contained in the application. The environmental health specialist is also not
responsible fo•r 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 ap�lication. Neither Per�on 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 O1/95 rev.1.1
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PERSON COUNTY ENVIRONiiENTAL HEALTH
WELL LOG
Date:' - �'' .
Owner. . e�.�-�e�
Locati,on/Directions:
Subdivision Name
Drilling Contractor:
SR## � � �/ ' . .
� .vn-� - - . .
rv�..��+�;j� ��L •��r��
••
. WELL CONSTRUCITON "
Dis[ance from Nearest Properry Line_ /� Distance from Source of
Pollution I o v '
Total.Dep.th: �vv Ft. Yield: 3 GPM Static Water Level d 5�
Ft.
Water Bearing Zones: Depth �Ft. �? Ft��F� �t.
� Casing: Depth: From_�_to .�S' Ft. Diameter:_ LQ /s� Inches
TYPE: Steel � Galvanized Steel �
If Steel, does owner approve: Yes No
Weight: � Thickness:_l b�.� HeightAbove Ground: I� 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 Inches
Water in A,rmular Space: Yes No
- - . Method: Pumped � Pressure � Poured � . _ - : .
Depth: From_ v to a c� Ft.
Materials Used: No. Bags Ponland Cement Weight of .1 bag__Ibs.
If mixture (sand, gravel, cuttings) - Ratio: to
ID PIates: Yes �' No � � � -
4 x 4 slab Yes � No
I HEREBY CERTIFY THAT THE ABOVE INFORMr�TION IS CORRECT AND TH AT
THTS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS
FORTH BY�THE PERSO�I C�Li�ITY HEALTH DEPARTMENT.
���" , _
Signature of Contractor D1tc
SET