A40 208. «
Site Evaluation Application
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Fee Collected YES
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Person County Heaith _ept.
325 S. hAorgan•Street
Roxboro, N.C. 27573
Courisr #02-33-i5
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NO
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APPLICATLON FOR IMPROVEMENTS PERHIT
1. Permit requested by: ownerl;�rospective owner:
agent:
Address: � � � � ���
Home Phone 4�: �C (�1� Q 6rj -C��� � Business E�none ��: � � K l
2. Name and address of ck rrent owr��gr: �-� � �
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3. Property Description: Lot size: �'��
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4. Tax map ��: Township:�
Subdivision Name: (�.�� �-� Q.s� Lot �i�:
S. Directions to property: State Road �� & Road Names, et .
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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? {� - public? _
Other source? (Specify):
Are there any wells on adjoining property?
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community? spring?
If so, �de�tifx 1Qcation:
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Type of structure or facility: Proposed: � �xisting:
Type of dwelling: House: Mobile Home: Business:
Type of business: �-0�--2 Number of Employees: .
Number of bedrooms: _� Garbage Disposal? Yes ro �
Basement? Yes No l/ 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.�
I hereby make application to the Person County Health Department for a site
evaluation or existing system 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.
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)
Signed Owner or Authorized Agent
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Permit Issued
Permit Denied
Plat Observed
i�ACTORS - SITE EVALUATION �_ AREA 1 � AREA 2 ARF.A 3 AREA 4
1. SLOPE (X)
2. SGZi TEXTURE (i2-36 in.)
�Sandy, loamy, ay y,
Note 2:1 clay)
?. SOZL STRUCTITRE (12-36 in.)
(Clayey soils)
4 . SOIL DEPTS (i.n. )
5. RESTRICTIVE HORIZONS (in.)
(Iutpervious Strata� rock)
6. SOIL DRAI2IAGE/GROUNDWATER
(External & Internal)
7. SOIL P�RMEABILITY
(Percolation Rate)
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g. OTHER (specify) PS PS PS PS •
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9. SITE CLASSIFICATI�JN
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECO2-R�tIDATIO NS / COMMF�ITS :
S:�_TE CLASSIFICATZON �TAGRAM (Znclude: Soil areas, property lines. roads, streams, gullies. ""
Wet areas, fill areas. Wells, c�ater bodies, slope patterns, etc.)
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A 0327
PER�ON CO LJI'�1TY HEAL`�H DEPARTMENT
" WELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT PERNIIT
Tax Map #�i � f Parcel #� C�'
Zoning Township F��'' �
Owner/Contractor T��� F� Date S=�2 2- 7'y
Location/Address �6�-c..� 1�'� •-�-�''—�. C o-�, -�� 1°-}`
S.R.#�L,,� )57�;.�zs%�
Subdivision Name F.��
Layout
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Lot# � D
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SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area /� /��L Size of Tank /�'-d-
SFD I/ Mobile Home c� Size of Pump Tank �i�
Business # of Bedrooms�_ Nitrification Line �a �' x� � i
Max Depth Trenche z
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or intended use changed. �
Well and Septic Layout by Lv �-� �
Comments:
Date'� �6- q,5' Installed by 6` ` Approved by L�,r�?..e .�S �u��
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WELL SYSTEM SPECIFICATIONS
Individual �� Semi-Public Required Slab 7�,L4 �
Public Replacement Air Vent ✓
Site Approved �� Required Well Loo
Well Head Approved �/ Well Tag o2 S
Grouting Approved '7 � �Y S
Comments:
Date / i Installed by ,� U/.'//,"�-so�1 Approved by
This report is based in part on infonnation provided the homeowner or his/her representative in the application submitted for this perciut The /
environmental health specialist is not responsible for false or misleading information contained in the applicatioa 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 apptication. Neither Person County nor the endvonntental 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\peinut.sam Ol/95 rev.1.0
ORIGINAL