A40 236� •, ti \• � �� � � � �
. F�er�on County Health Department �
Sewage System Improvements Permit
Date: ��1L.. This Permit Void After 5}'ears �Per�r►i�t #�� ,�L2�Z-
Owner. L ,'.�.�a �/a�s �o„�//�� r'�Br�=� SR#��.
Location/DirecUons: ��' `�
Subdivision Name• f- /��"' /���i p v ,f'!i, ri fn ��, �.. Lot #�,L� -
Lot Size: �; �-� �� Y e Type of Dwelling:
Water Supply: Private: _1� Public: Community:
Beciroom� 3 Gazbage Disposal
Basement Basement Fixtures_ �
INFORMATI D BY G� �" `
S8I11f811N1: �„�"' owner or rep tauve Z_
REPAIR: REEVALUATION: p�
Size of Septic Tank: �d �p gallons Size of Pump Tank: U`
Nitrification Line: �
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System:�c onv. Pump LPP Pump
Remarks: � 11, , ,� .,,.� .� _L� "L� „�,e /_-t- ✓►,Q�' p r,� :�f.�,
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Date Well A ved: Well shoul���00 f� from an sewer s stem
PPro Y Y
BY Sanitarian
Date Sewage System Approved: �' - �3 - 43
BY Sanitarian
CERTIFICATE OF COMPLETION �
Contractor. �
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Sewage System location, installation, and protection must meet state and local �
regulations. Sepric tank should be pumped out every 3 to 5 yeazs and shall be maintaine�
by owner in such manner as not to create a public health hazard. Septic tank and �
niuification line must be inspected and approved by a member of the Person Counry
Health Departrnent before any portion of the installation is covered and put into use. If 0
the site plans ar intended use change this petrnit is subject to revocation.
(G.S. 130 A-335F) T�,
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Locadon of sewage disposal sewage system sketched on back. t
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(OVER) �
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�rson County Health Department �
� Well Permit �
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Date:�� 's Pcrmit Voi Afcer 3 Years
Owner: r1►� ��,[� F'"' s� �
Location/Directions: - S'a i 1 � -
. � • - �L'��:l��I
� . � . . "��l'-�Yr�lll�����
� y: yr.
Distance from Nearest Prop�Y �e Distance from Source of
Polludon G
Tatal Depth: FG Yield: .�s_L�GPM Stadc Water L,evel p�,
Water Bearing Zoncs: Dept� �t.,__ Ft. Ft. Ft.
Casing: Depth: From S�� to l F� Diameter: �� Inches
T'YPE: Steel Galver►ized Stee�
If Steel. does owner approve: No
�rye1��; 'T'hiclrness: Height Above Ground: Inches
Drive Shce: Yes No
Were Problems En�untered in Setting the Casing? Yes No
If "yes" give reason. i
GrouG Type: Neat a�d/Cement` Concrete
Annular Space Width l� Inches
Water in prmular Space: Yes No
Method: Pumped_�. Pressure Poured �
Depth From �_ toz� FG
Materials Userl: No. Bags Pordand Cement Weight of 1 bag
lbs.
If miztuze (sand gTavel�uttings) - Ratio: � -
ID Plates: Yes �,�_ No
4 x 4 slab Yes No
I HEREBY CERTIFY THAT THE ABOVE WFORMATION IS CORREGT AND THAT
'fHIS WELL WAS CONSTRUCI'ED IN ACCORDANCE WTTH R�CGULATIONS SET
FORTH BY THE PERSON C�L1N!'Y H�'HrI�EPAR'FMENT. r
Date Lssued
Sanitarian's Signature Date Completed
Sketch well locadon on reverse side.
, ,� ..- . � _
Site Evaluation Application Date:
Fee Collected YES O� MO
d �-��° q�34-
p��� APPLICATIOId FOR IMPROVF�`fENTS PERHIT
�.J�� - - -
1. Permit requesLed by: own�/prospective owner: r�,
agent:
Address: � � C�/`��S�O £/� w
Home Phone 4�: �'j�/O $T%% s�Fi � Business Phone �r`:
2. Name and address of current owrier:
3. Property Description: Lot size: �.,�J �C�,�
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4. Tax map ��: � b-oZ Township:
Subdivision Name: tv� �� !9-ic• ,!4 �o,U Lot ��: �%3
5. Directip ns to pro erty: State Road �� & Road Names, etc/
v d� � � < � - l � �. e X bd/�i-a C[ '�" ll � /
v L �L o �
d C'� C D i �l/ - '% � t
6. Permit requested for: New Installation: Repair:
A itio 1 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?
�dd Q- ( 7- X l 2 !`� � N I/�% /� Da N1 �
10. Water supply private? public? community? spring?
Other source? (Specify):
Are there any wells on adjoining property? If so, identify location:
11, Type of structure or facility:
Type of dwelling: House: ^
Type of business:
Number of bedrooms:
Basement? Yes ho
Proposed: Existing:
Mobile Home: Business:
Number of Employees:
Garbage Disposal? Yes No
If so, number of basement fixtures:
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 existin� 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)
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.Sign d Owner or Authorized Agent
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Permit Issued
Permit Denied
Plat Observed
i?ACTORS - SITE EVALUATION AREA 1 AREA 2 ARFA 3 ARF.A 4
1. SLOPE (X)
2. SGIL TEXTURE (i2-36 in.)
(Sandy, Ioamy, clayey,
Note 2:1 clay)
?. SOIL STRUCTURE (12-36 i.n.)
(Clayey soils)
4• SOIL DEPTH (in.)
5. RESTRICTNE HORIZONS (in.)
(Im{�ervious Strata. rock)
6. SOIL DRAIIIAGE/GROUNDWATER
(bcternal & Internal)
7. SOIL P�RMEt�BILITY
(Percolation Rate)
$ . OTHER (specify)
S
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9. SITE CLASSIFICATZ�JN
(See below)
SOZL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECO2�II�NDATZONS /COMMII�ITS :
S:�:TE CLASSIFICATZON JLAGRAM (Znclude: Soil areas, property lines. roads, streams, gullies.
Wet areas, fill areas, Wells, water bodies, sZope patterns, etc.)
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. �� A0178
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERNIIT
Tax Map #� 1 f. p 1� " Parcel #� 3�
Zoning Townslup
Owner/Contractor�°�tu,.P ' ` Date �}-- 4<- - 9�
Location/Address B,� .�•lu �, : , 3-�-�=" /�-.�. 1E'��,G-�-��-
S.R.# / S7 ...�-�'.4
Subdivision Name�'�;�,�s�.•�. P -��.. Lot# �'p P
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area Size of Tank /�o-� ` ` �
SFD V Mobile Home � Size of Pump Tank d��vC `'
Business # of Bedrooms 3 Nitrification Line �Eoo�X3� ���-�`-�-,�g�
Max Depth Trenches , ' '
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����, � GU.,t�-2 a�-�-«�-�.�
Comments:
Date - 9'S Installed by�a ' � Approved by !�r/��2-� .c9 �•.-�,,a,�,
Individual
Public
Site Appr vec
Well H d Ap
Grouti g App:
Co ents:
Dat /
by
SYSTEM
Required Slab _
Air Vent
Required W 11 LQ�
Well Tag
Approved
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this pennit The
environmental health specialist is not responsible for false or misleading infonnation contained in the application The environmental heatth specialist
is also not responsible for concealed conditions on the property or for statements in this repoR that may have resulted from false or misleading
statements provided to him in the application. Neither Petson County nor the envitonmental health specialist warrants that the septic tank system will
continue to function satisfactorily in the futu�e or that the water supply will remain potable. c:lamipro�permitsam O1/95 rev.1.0
ORIGINAL