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.eceipt .0� ' � � Date
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�PPLICATION FOR SERVIC�S
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=s � 4 ;_ �,� .� � � �z�� .� �� SeCVICG.SiRequesfed ... �.,� .�
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Improvements Permit.((Established/Recorded Lot) ._ Reinspection of Existing System (Loan Closing)
Impxovements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) ,_ Permit for New Well
Improvements Permit (Addition) _ Replace Existing Well
Bacteria
1. Permit requested by:
�wner/prospective own�
Address: . �v
ar �„� ., _ �
z
,. _x .: ,,.-., _ ......... .... .
Chemical Petroleum Pesticide _ Lead
ome Phone #: '
usiness Phone #: -
7. Dimensions or Proposed Structure:
Width: �
2� � 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 addre�s of,current owner:
. Property Description: Lot size:
. Tax Map#: �-° �'
Parcel#: �� �
Township: �
�. Directions to property: State Road #& Road
ames,�tc.
9. Water su ply ty pe:
private public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No [�.
If so, identify location:
10. Type of structure/facility: Proposed: �Existing: Q
Type of dwelling:
House: ❑ Mobile Home: usiness: ❑
Type of business:
Number of Employe�s: �
Number of bedrooms: �— �
Garbage Disposal? Yes ❑ No 0
Basement? Yes ❑ No� If so, # of basement fixtures:
Number of occupants or people to be served: � —
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PerS0I1 COUn�y I3Calth DepaTtmeni for a site�es auali° tion ahe �rue ite
sewage disposal system for the above described property. I agree that the contents of t pp
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 ttiat 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.
Si�ne Owner or Authorized Agent
Permit Issued ❑ Signature Date -
Permit Denied ❑
Plat Observed ❑ � �"
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'1. SlAPE(%) S S S S
PS PS PS PS
U. U U ' U
2 SOII.TEX7URE(12-36INJ 5 S--_.. ... S S
(SA1iDY. LOAMY. CIAYEY. NOTE 2:l C1An PS PS PS __- PS ' ._
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3. SOILS7RUCiUREp2-36IH.) S S S S -
(CLAYEY SOII.S) PS PS PS PS -
U U U ' U ,
S. SOILDEPiti(IN.) S S S S
' PS PS PS PS
U U U U
S. RESTRIC7]VEHORRONS (TNJ _ 5 ' S ; _ .. � -. S . ,'. .. . r . �. .. S -.._
(IMPERVIOUS STRATA, ROCK) PS PS PS PS `
-_...
_, ., U. . _ V p.::. . -.:,. U
6. SOILDRAINAGFIGROUNDWA'fER '. S S S S � �.
(EJCTEItNAI, k II�7'FANAL) PS PS PS _ PS
U V U U
J: SOII.PERMEABILirY S S S S
(PF�cCOLAATION RATE� PS PS ' PS • PS
_ _ . _ _. .. U U - U U �
E. AVAIIaBLESPACE . S . S . S : g
PS PS PS PS
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9. SITECLASSiF7GT70N(SEEBELOVh � � ' ' • - • ., , '
- � ,.. • :
SOIL SFRIES .';`:_ . .: ' : .. . .: .. - - .
- S-SUITABLE `PSPROVISIONALLYSUITADI,E U•UNSUTIABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, �11
areas, wells, water bodies, slope pattems� CIC.� C:�AM(PR0IDOCS�APPSEC.5�1 FWANCE.PC ..
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT 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 # �
Owner/Contractor
Location/A�dress
Zn or
Subdivision Name
Parcel #_
Tow ship
C��-e <
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Date �U—�y—
S.R.#
Lot#���
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SEWAGE SYSTEM SPECIFICATIONS
�ir Lot Area� . LI 1 f� �
f Mobile Home ✓
ness # of Bedrooms�_
Permits may be voided if
Well and Septic L�put by_
or
Size of Tank QCUC
Size ofPump Tank A-�
Nitrification Line L.� [�•
Max Depth Trenches�
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e �� nstalled by Approved by (.cJ..�O .L� �-�w,.�.
- � - . G-'�`'�
ell Permit Paid WELL SYSTEM SPECIFICATIONS
-Public
Public Replacement
Site Approved � _
Well Head Approved
Grouting Approved G�a�,�� I/-/D-98 �
Comments:
Required Slab "
Air Vent
Required Well Log I Z 4 L
Well Tag
Date � �— ���O y Installed by ����.J� ((�,- ;�(; p,c�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 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 i� the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
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North Carolina - DepartmenC of Environment and Na[ura� Resaurces - Qivis�on ot Water Quality • Groundwater Sect�on
P.O_ Box 29578 - Raleigh.N_C. 27626-0578-Phone {919) 733-3221 '
" WELL CONSTRUCTION RECORD DRILLINGCON7RACT�R: �"i"4` ��� �kc
QRILLER REGISiRAT(ON #:
STATE WELL CONSTRUCitON PERMIT#:
WE�L USE �cna�x appucab�e eoa�: Residential C� Municipal ❑ Industrial n
Recovory ❑ Heat Pump Water Injection ❑ 4ther (� If Other. List Use:
Agric�Iturai ❑ Monitorfng ❑
2. W��� LOCAT N: (Show sketch of the location beloNr) �p
Nearest Town: �� County: 1� �S �--
��-2s P..t�� �,. � � ��� � 2�
(Roaa, co munrty, or Sub N� �On and Lot No.) DEPTH
3. OWNER �s From 70
ADDRESS �5 d ,.,..
j� LC �y 6e r� l(Street or,Rpute No,) �����j —
L. � L
Gity or 7own � Sta�e z�p Code —
4. DATE DRILLED ��' +�„�_ p . �
5. TOTAL pEPTH _.�ti,,,_ n�,
6. CUTTINGS COLLECTED YES ❑ NOQ�
7. DOES WELL REPLACE EXISTING WELL? YES � NO� `.�-�r ��6
8. STATIC WAT�R LEVE� �etow Top ot Casing: �3�_ FT.
(Use''+" i1 Abova Top o� Casing)
9. 70P OF CASING !S i FT. Above Land Surlace'
' Casing Terminaiea avor nelow lana surtace Is Illegal unless a vanance Is tssuea
irt accordance with �5A NCAC 2C -atts
10. YIELQ {gpm): �_ METHOD OF TES7 �-4L'— �� �-
i �. WATER ZONES (depthj: ( ib -,�40
DRILLING LOG
Forma�ion Oescription
12. CFiLORINA710N: Type ��� Amount � If additional space ls needed use back oi form
13_ CASING:
wau Tnic�r,�ss LOCATION SKETCH
F'rom �� � DToth �a� e�er or11r eiphL'Ft. M�af�riai (Show direction and distance irom a[ leaet two State
��) Ft, � � ��- Roads. or other map reference points)
From To Ft_ —
From To Ft_ —
Y4. GROU'T: ,,5�
/p Depth Mat rial Method
From S.�_ To �— Ft. �C�
From To Ft.
15. SCR�EN: R,� (�,Y t`p
Depth Diameter Slot Size Malerial
From To Ft —
�rom To Ft.—
From To Ft_ _
16. SAND/GRAVEL PAGK:
�epth
From To Ft.
From To Ft.
17_ REMARKS:
_ in. in.
_ in. in_
_ i�t. in.
Size Material
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� oo HER�BY CeRr�FY'fHa'T TH�S WE�I. wAS C�NSTRucrEp �N AGGOROANCE WITH 15A NCAC 2C, wELL
GONSTRt1CT10N STANDARDS, AND TWAT A GOPY OF TI�IS RECORO H BE 'N PROVID�D TO THE WELL OWNER.
Fq .o�F .���;Us'� A�!�: �} .,, (� � d.�--�- � l -- L (
�u�d I�i��*n^'.,i�X�r���.a,�', .+ '
,`�,fi,�riAT�f�°:�r�d1;�� �aqb�°���.
, . .: , . .
.�.�,�,y,�:.,• �.:,,�� : r,
i�"�� hT�r.}.'":'Yn1
SIGN�TURE OF CON7RACTQR OR AGENY DATE
S�t]inil O/i9�nai lo DN�S�o� 0� w�ter �ualiry and copy to v�eU ownnr.
G4Y-1 REV. 1/�J8
T0'd Tb6T 8ZS 6T6 7NI�NI'11I2lQ1"13M3�H Wd tS:60 Q3M 86—T T-1\ON
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