A40 217z
- ' • �?erson County Health Department �
� Sewage System Improvements Permit
Date: �C��'Fhis Permit Void �ft�er 5 Yea�s �,,, PPrmit # ' y
Owner ��-LS-_K.�! .�� � � " n � 1-�-� rt e � v � �S 7
Location/Directions: � � � �S� vH4
Subdivision Name: I— / G. / il f �/�y / � G �7 / �-a ! o n Lot # � �
Lot Size: � Type of Dwelling:
Water Supply: Private: Public: Community:
Bedrooms: 1 � Garbage Disposal '
Basement Basement Fixtures
INFORMATION CERTIFIED BYS/� �� � /�n .5 I� ���+'
Environmental Health Specialist: o er or rep e racive
REPAIR: REEVA�,UATIO :
Size of Septic Tank: �-�b � gallons �Size of Pump Tank:
Nitrification Line: /�/� � �? �' —'
Depth of Stone: 12.inches '
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks:
Date Well Approved:
BY
Date S a S te A mv
BY � �����%��� �,
Contractor:
Well should be 100 fG from any sewer system
Environmental Health Specialist
Sewage System location, installation, and protection must meet state and local
regulations. Septic tanlc should be pumped out every 3 to 5 years and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and
nirsi�cation line must be inspected and approved by a member of the Person Counry
Health Department before any portion of the installation is covered and put into use. If
the site plans or intended use change this permit is subject to revocation.
(G.S. 130 A-335F)
I.ocation of sewage disposal sewage system sketched on back.
(OVER)
�TO�E: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
su plies, etc. Note special problecns existing on lot. Write in measurements in order that installations may be located
nt �later date Note location of water suoolies o� djacent lots.
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ati+o�/D'uectnons: _
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T� -�� i�t. Yidd:�_ �P�% � Smtic W�ar Levet �,�
. W��&�= ���k . _� . -
' �8" Tk�th: �r-�--m_: �� 1r'arn , r
TYP�.�Steel � ��
If 5�ee1, does awner ap�r�ore• Yes o
Wcigh��_77�ic1auss:�jir�g AboveGmvnd:�L�hea
Drive Shne: Yes `--Na
Were Probleans Enaovrttered 'oi Sett�g the Casing? Yes No t_ —
If "yes" give reason:
Cva� Type; Neat $����__��e
�knwiarSp�c� W'
Waux u�c�4tmidar Sp� Yea ]�o C�
Mcda�d: Pum�ed pt,�� ����
Maierials Usad: No. ��c
_If miamne (sand. gtav� Pb¢iJsa�d Cem 1Veight of 1 bag��b�.
ID Plsaes: Yes� )-�atin: to 1
�T �
�SET
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��`a Datelasued
Suiitszian's SiB� Da� Compieoed
�etch we1] locarion aai r+evease. side.
.
Sute ��aluation Application
Fee Collected YES ��
�d 10�•� 33�`�
R��'�# q 5z
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1.
Date: 4'�4-`�q
NO
APPLICATION FOR IHPROVEMENTS PEEtHIT
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Permit requested by: owner/prospective owner: .�.2uGti �-C �`/N� �'"�-`/c"r`T �
� Q agent:
Address: 1 � � �y�-'ti�- �•�1-' O�i
Home Phone ��: � p . Business Phone ��:
2. Name and address of current owner:
ir��24 �i
3. Property Description: Lot size: �� a 9 /.tc.
/�Y�c.�
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4. Tax map ��: Townships
Subdivision Name: ,Gl�4`T �«�c .G4•� tT�4�� Lot ��:
5. Directions to property: State Road �� & Road Names, etc.
3
6. Permit requested fo"r: New Installation: ✓ Repair: .
� Additional Renovation re-using present system:
7. Number of occupants or people to be served: �
8. Dimensions of Proposed Structure: Width: C� Depth: `
9.
10.
11,
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?
Water supply private? '� public? community? spring?
Other source? (Specify):
Are there any wells on adjoining property? t/ If so, identify location:
Type of structure or facility: Proposed: � E�isting:
Type of dwell.ing: House: Mobile Home: ✓ Business: _
Type of business: Number of Emp,loyees:
Number of bedrooms: Z Garbage Disposal? Yes No �I
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•I
�
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 �ltered 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)
�tiv�cr- � 5��. � ���� _ .
�8�'"��� Signed Owner or Au horized Agent
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Permit Issued �J
Permit Denied
Plat Observed � �
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I�ACTORS — SITE EVALUATION AREA 1 AREA Z AREA 3 AREA 4
S S ' S S
1. SLOPE (X) � PS PS PS PS
U U U U
2. SOLL TEXTURE (12-36 in.) S �.S S S
(Saady, Ioamy, clayey, ps p
Note 2:1 cla ) U j U U
3. SOIL STRUCTLTRE (12-36 in. ) S S S S
(Clayey soils) PS PS PS PS
U U U U
S S S S
4. SOIL DEPTH (i.n. ) PS PS PS PS
U U U U ..
5. RESTRTCTNE HORIZONS (itt: ) � S 'S S S
(I�ervious Strata, rock) PS PS PS PS
U ' U U U
6. SOIL DRAINAGE/GROUNDWATER � S S S S •
(EScternal & Intercial) PS PS PS PS �
U U U U.:
7. SOIL PERMEABILITY S ' S S S
(Percolation Rate) PS PS PS PS
U U U U
� S S S S
$. OTHER <specify) PS PS � PS PS �
� U U U U
g. SITE CLASS,FICATZON � � � � �
(See below
SOIL SERIES
S- Suitable . PS - Provisionally Suitable � U- Unsuitable
RECOtR4ENDATIONS /COr4tErITS :
SXTE CLASSIFZCATION DLAGRAH (Includes Scil areas, property lines. roads, streams, gulZies,
Wet areas, fill areas, aells. water bodies, s2ope patterns, etc.)
04-18-94 0�:29PM
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pet�son �County l�ealth i3�:p�rtment �
Sewage S��t�m lmprovements Permit �
Date; �..,� �This Pernsit V�,ntd J�ftFr S��Ytar� �t' �,�'�"� l.�w
tawnar: ��V,�O � �. n � � �^7�
�.oc+uioNgireeti.ons: '' � —•��--°��-�---�
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5ubdivlsionNa�nC.'�1.� _ o�► Loi#
[,ot s1ze: l.� 'I�p� os nv�tting ..
Wa�cr Su�1y: Privata � �+��c:...... Cot'nmunity: �. .--
Hedn�ms:.� _ �� �� �
$asemc�t .. �ascmentFixwres f,:�„��
g�p,Ug: �,_ REEYI�L.UATiON� � _ _�
_._�......,..����...,----�.--......�...�...._.__.�._
Sisc of Scpdc Tpnk: fi� �Ms Siu af Purap'Panic: _�,_---
2�Iitrificati� Lin�: — .
Ae�th of Stoi►c: 12 i�tr�s -�---��
Max D�{31h Of TtCtlCi�ts:_�.. 1. wr...
Alt�ar�ativa SyS�n: Co�v. PnmP .-- -- - L.i�' Fua+p _.._
Remazks: _ �.
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D4te 1�Ve1! Apprctvc�---.— Wall #souFd ba IUUU it. fmm a�y s�w�' ��
SY �vir4�metit�t Hes�th SD�llss
r>ace s�� sy9ce�rz n�vaa:
SY...—.--- �aviz!otsrntntt�l Health SpocialiSt
CEItT1�t�CA7E 0� �JO1�PL�ON — �
�vnaic�or.._...� 6�
..._�.�....�_�.......__--._._�—_._.....__..r:�_—.--
8ow�ga Syswm Ioc�daati, inscatladoa � pro�n muac raert �o u�d }oc� �
=agnlatiaa�s. Sepdc tu�t a}+culd bs p�npad ant avary 3 w 3 yesn �axl tt�alf ix m�itstt�xd
by owncr in snch mWu►at es nas u> care�ta s �xtWia hcYJch haud 5ep1i4 rmnk �nd
t,�:riGcatioa Wyv must be i�upacLcd wd appcoYed bY a mcmber o! tha t�arsms Ccua+Y
Hc�ith Dep�c befar� u�y 1��on o! c�e irut*tiacion ts eaveaed �:+d put y►to ue. I(
3he sice pla�s pr irAstKlod tLSe chaa�e thi3 pe3tsfit iF subj�ct �o revocatiat+.
{GS,13D A•33SFj
Lacauvt► At caw�c diK�osat sawrzo syat�a aknteh�d ost i�7c.
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