A35 10The District Health Department
Orange, Person Chatham, Lee Counties
SEPTIC 1'ANK PERMIT
Date � � � " '� �
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Name of owner .�'�" "`•'-a �, i�' `'° ' s r
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Address and Directions � �-'f � "� '�� '�'�f � �? �"� x `� `' `
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Person or firm doing installation:
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Address
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No. of persons to be served bedrooms 1, 2, 3, 4.
Additional appliances to be used: Disposal, dishwasher, washing
machine
Minimum Requirements: Septic tank �� �"� �''� � "
Nitrification line: � �''��' r�-S . '" �
Septic tank and nitrification line must be inspecfed and approved by
a member of the Healfh Deparlment staff before any portion of the .
instaliation is covered.
Date Approved: .�% ` ,: ''�.
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By. - / t7 — S�_
� O. David Garvin, M.D., M.P.H.
District Health Officer
Countersigned
(Over)
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NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on
adjacent property, etc. Write in measurements in order that installations may be located at later
• date.
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. Person County Health Department �
�L Well Permit �
Date:s�-��Vt"his Permit Void ter 3 Years
Owner: j_ �^� 9-y � L � �t,
Location/Directions: �
,.� _ St'r'�'2-��l .,., � ✓_: -, i"
Subdivision Name:
Drilling Contractor:
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SR# ����
' J `t�' Ixj�re S(i1�
Lot #
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Distance from Nearest Property Line f�'�Q /w S Distance from Source of F�'
Pollution !� /� �
Total Depth: � reld: �GPM taric Water Level Ft. �
Water Bearing 7�}ones: Depth 9� Ft % FG F� FG
Casing: Dept�h: From � to � Diameter: � Inches .
TYPE: Steel Galvanized Steel -�
If Steel, does owner approve: Yes No
Weigh� �_ Ttuclrness: � Height Above Ground: � Inches
Drive Shce: Yes `"'-- No
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason: 'Zi
GrouG Type: Neat �� Sand/Cement Concrete �
Annular Space Width -3 Inches
Water in Annular Space: Yes No ��
Method: Pumped Pressure Poured ''��
Depth: From D to �� F�
Materials Used: No. Bags Portland Cement �_ Weight of 1 bag
� Ibs. •
If mixture (sand, gravel, cuttings) - Ratio: _� to _�_
ID Plates: Yes (/ No rd
4 x 4 slab Yes —�` No ;;
I HEREBY CER'TIFY THAT THE QBOVE INFORMATION IS CORRECT AND THAT
T�IIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT.
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Date
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Date Issued
Sanitarians Signature Date Completed
Sketch well location on reverse side.
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�TOTE: Make sketch of � ation 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 installations may be located
�t later date. Note location of water supplies on adjacent lots.
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # Parcel #
Zoning Townshin � o s
� � �,► • �
Owner/Contractor.
Location/Address
S.R.#
Subdivision Name Lot#.
Permit Void after 60 months. Permit V'
Permits may be voided if site is alte � i
Well and Septic Layout by
���
if not in compliance with zoning regulations. �e �e�'� �
n n d u changed � ��
P �"�%� !
IWell Permit Paid ❑ WELL SYSTEM SPEC��'ATIONS �
vidual Semi-Publ
lic Rep ze
Site Approved
Well H pproved
Grouting Approved
Comments:
Installed by
�
Required Slab _
Air Vent
Re u' ell Log
ell Tag
by
This report is based i� part on information provided the homeowner or his/h�er representative in the applicafion submitted for this permit. 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 propeRy or for statements in this report that may have resulted from false or
misleading statements provided ro him in the application. Neither Person County nor the environmental health specialist wairants that the septic
tank system will continue to function satisfactorily in the future or that the water supply will remain potabte. c:�amipro\permit.sam 01/95 rev.1.0
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APPLICATION FOR SERVICES
Improvements Permit. (Established/Recorded Lot)
�mAxovements Permit (Unrecorded Lot)
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Reinspection of Existing System (Loan Closing)
,_ Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) _ Permit for New Well
' Improvements Permit (Addition) _ Replace Existing Well
V'�'ater Sample;io be ;Collecfed: ;
;;, , � :. ; . . . .
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_ Bacteria _ Chemical _ Petroleum _ Pesticide
1. Permit requested by: ��,
Phone #: J � '� —
usiness Phone #: - �
7. Dimensions or Proposed Structure:
Width: 1 <} X � O
_ Lead
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?
Name and address of current owner: 9. Water suppl type:
�� a�e private public ❑ community �� spring ❑
Are any wells on adjoining property?Yes ❑ No [j.
If so, identify location:
Lot size:
. Tax Map#: A 3-S Fo r
Parcel#: � � �°`rµ
Township: W�Q.G S da�� �S�
. Directions to property: State Road #& Road
Tames,�tc.
Number of occupants or people to be served:
0. Type of structure/facility: Proposed: {�E
'ype of dwelling: ��/
House: ❑ Mobile Home:-�l ]3usiness: ❑
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Type of business:
Number of Employees:�_
Number of bedrooms: 3 F
Garbage Disposal? Yes ❑ No �
Basement? Yes ❑ No�I 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 Pet'SOn COunty Health Department 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.
Signec� Owner or Aut�iorized Agent
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Permit Issued LY
Permit Denied �❑.,,/
Plat Observed l�
Signature Date S ( ' ��
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<;. . " ,. ' ;. �ACI'ORS-SIIE EVALUkTIOti ;': j.. . ; . ARF� �; . . ; AREX 2 IiREA3 <i A1tF114
_ ..__ .
1. SLOPE (%) ,�7 S S S
P O�. L-/ PS PS PS
✓ �'� U U U
2. SOII. TEXNRE (12•36 IN.) S S S S
(SANDY, LOAMY. CLAYEY, NOTE 2:1 CLA]� S � PS PS PS
U U U
3. SOIL S7TtUCiURE (12-361N.) S ^n S S S
(CLAYEY SO1LS) S ��y/ C PS PS PS
���/ U U U ,
3, SOtI. DEPT}i (IN.) S S 5 S
S ?% � � PS PS PS
./ « U U U
S. RESTRICTIVEHORIZONS(IN.) S S S
(IMPERVIOUS STRATA. ROCK) S N� PS PS PS
U U U
6. SOII,DRAINAG&GROUNDWATER S S S S
(FJCIERNAL �k INiERNAL) 5� A 1� PS PS PS
�v�� U U U
7. SOII. PERMEABII.iCY S S S
(PERCOLOA7ION RATE) S � � PS PS PS
U U U
S. AVpII.pBLE SPACE S I, S S S
PS f\ K PS PS PS
V'\ U U U
9. SiiECLASSIFiCA770N(SEEBELOW)
SOII, SERIfS
S-SUITABLE PSPROVISIONALLYSUTI'ABI,E U•UNSUITABLE
RECOMMENDATIONS/COMMENTS :
STTE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope pattems, eCC.� C:WMiPRO�DOCSWPPSEC.SM FINANCE.PC
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B 1064
PERSON COUNTY HEALTI� TJEPPL�.?'�?E'�?'I' " '
~ WELL AND SEWAGE SITE, LOCATION IMI'ROVEMENT PERMIT
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
has been issued.
T� Map # � �� Parcel #
Zoning Township
Owner/Contractor �.r ��//. Jv, Date .� = /— �i(,
Location/Address /3 S� ! 3 3�" o f a �?'�f
rl '� i�i a �a.� �,�,,,. S.R.# � 3�
Subdivision Name
Lot#
SEWAGE SYSTEM SPECIFICATIONS
Lot Area �� � t �c. Size of Tank /�(%� f 1`'x.� �1 �
Mobile Home Size of Pump Ta—'nk �� ��
# of Bedrooms_� Nitrification Line�Q }( 3
Max Depth Trenches � �� ��
Permits may be voided if site is
Well and Septic Layout by
Comments:
Date
use c,Ipanged.
Installed by �_ (� �� s Approved by,
Well Permit �aid ❑
Individ
Pu
j ,� rte Approv
" '� Well H Appro
� Gro ng Ap ved
mment . '
Date Ir
SYSTEM SPECIFICATIONS
�mi-Public Required Slab
Replac nt Air Vent
Re ' Well Log
_ ell Tag
by.
Approved by
T'his report is based in part on information provided the I�omeowner or his/her
representative in the application submitted for this permit. 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:\amipro\permit.sam O1/95 rev.l.l