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A40 237z . . �erson County Health Department � Sewage System Improvements Permit Date: "� ' Permit Void After 5 Years Permit # �`� �� Owner: SR# L.ocation/Directions: `' " Subdivision N e: 1l�` ��''v �. h 7� Lot # Lot Size: Type of Dwelling: Water Supply: Private: Public: Community: Bedinoms: � Garbage Disposal Basement Basement Fixt}x�, '��—� INFORMAT� CF,Y�TTi6IEA BY _ _ , ( .. ti REPAIR: (1 `� ' _ REEVALUATION: ---------- ----------�--- Size of Septic Tank: all � Size of Pump Tank: Niuification Line: � Depth of Stone: 12 inches Max Depth of Trenches: Altemative System: Conv. Pump LPP Pump Remarks: ------------------------- Date Well Approved: Well should be 100 f� from any sewer system BY Sanitarian Date Sewage System Approved: BY Sanitarian CERTIFICATE OF COMPLETION Contractor. ------------------------- Sewage System location, installation, and protection must meet state and lceal regulations. Septic tank should be pumped out every 3 to 5 years and shall be maintained by owner in such manner as not to create a public healih hazard. Septic tank and nitrification 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 the site plans ar intended use change this permit is subject w revocation. (G.S. 130 A-335F) Location of sewage disposal sewage system sketched on back. i � � � �' � �^-�� y �C..., G.� S=-. �� NOTE: Make sketch o! installation showing lot size and shape, location oi house, septic tanks, privies, water ,+.upplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located t�t later date. Note location of water supplies on adjacent lots. � (1) (2) � n�n : _ ■��'�� ■ ■��■��■��■��■�■■ ■C�� J��r'/.1�■ ■��■ ■��aG��%��1■ ■��■ ■/��: i�i�� ■��■ ■[l��I�■��//�■ �l�S ■��■��■■ ■��!�iiii�■�� ■■��■��■ ■��C:i��' ��L'i�■��■��■ ■��fi�ri��'��■��■ ■�■��■■��■��■��■�■■ ■�■��■��■■�■��s��n�■ ■��■��■ ■W�v �-erson County Health Department ` Well Permit Date ='�' �� This Permit Void After 5 Years� Owner. �� T! � r'� �� .� F�� j b. �� SR# � Location/Directions: � ,� Subdivision Name: `� � ' Lot # Drilling Contractor: WELL CONSTRUCTION Distance from Nearest Property Line Distance fmm Source of Pollution Total Depth: Ft Yield: GPM Static Water Level Ft Water Bearing Zones: Depth Ft. Ft FG Ft Casing: Depth: From to Ft. Diameter: Inches TYPE: Steel Galvanized Steel If Steel, does owner approve: Yes No Weigh� Thickness: Height Above Ground: Inches Drive Shoe: Yes No Were Problems Encountered in Setting the Casing? Yes No If "yes" give reason: Grout: Type: Neat Sand/Cement Concrete Annular Space Width Inches Water in Aimulaz Space: Yes No . Method: Pumped Pressure Poured , Depth: From to FG Materials Used: No. Bags Portland Cement Weight of 1 bag_lbs. If mixture (sand, gravel, cuttings) - Ratio: to ID Plates: Yes No 4 x 4 slab Yes No I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. Sigu�e q� Con}#acy�r Date /', ;', < f� /� P �. j i i/ � �i ! ,� �_ :, �� J}%" �'• t (�- anitarian's Signa ure Date Issued Sanitarian's Signature Date Completed Sketch well location on reverse side. b � z NQTE: Make sketch of installation 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 1¢cated at later date. Note location of water supplies on adjacent lots. . , Apr-23-97 07:12A Barnette Well Co. 910 599 0015 PERSOii COUNTY ENyIRpNMEpTAL HEALTH WELL LOG Owner: Subdivisian 3�tame: Drilling Contra�ior: SR# Lot # ......� ��„ Distance from Nearest property Line �C.3 Discance from Source of Pol�u[ion /GU - Total.Dep.th:. a.v F� Yield:_ a� GpIvI Static Water Level r V�i�ter Bearing Zones: Depth 7G FL�F� - F� �--�--._._Ft. Casing: Depth: From�_to��_Ft. Diameter• ` Inches TYPE: Steel � GalvaniZed Steel v��— If Sieel, daes owner approve: y� �jo �eight:;_____ Thiekness: �"—" ��,.Height Above Ground:_ I �l Inches I?rive Shoe: Yes ✓ No �Vere Problems Encountered in Sett;ng the Ca�ing� y� �� V If "yes" give reason: Grout: Tyge: Neat San�jCement ✓ Atuiular Space Width SncheS Coriclecc Water in Ann.iilaz Spac�: Yes �a .. Method: Pumged Fressure�� Aoured�,� � - � Depth: Fmm --�--�--� --�--� �—a o Fc. . 11�Iaterials Used: No. Bags Portland Cement Weight af .1 bag_____lbs. If mixture (sand, gravel, cnttings} - Ratio: to ID Plates: Yes � No ' � ------- 4 x 4 sIab Yes _.._ �o I HEREBY CERTIFY THAT THE ABOVE TNFORIvt�1TIpN IS CpRRECT AT1D THAT THIS WELL WAS CONSTRUCTED zN ACCORDAI�ICE �TTH REGULATIONS SET fi�RTH AY�THE PERSO�I Cvu��TY HEAL"FH DEPARTME�I'['. � . �. S�gnaturc o[ Concraccor D:,c�.�� An�^unt. paid � �.dc�� ' ��` �_ �_ / " - Receipt .��` ' 1�� ' Date • . . _ _ _ _ � � � .�.�.��[iTl�T[1 � M � � � w U � a Improvements Permit.(Established/Recorded Lot) ImpFovements Permit (Unrecorded Lot) improvements Permit (Mobile Home Replace� Improvements Permit (Addition) of Existing System (Loan Closing) RepaidReplace existing Septic System Permit for New Well , Replace Existing Well 1. Permit requested by: . 7. Dimensions or Proposed Structure: I �wner/nros�ectiveowner/agent: -L) �� -� Width: ¢ z ress: • - ` — ' _ 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? ome Phone #: � � usiness Phone #: . Name and addre s of: . , .,_„ � r. LBo �qG Tax Map#: Parcel#: _ Township: r_ ner: 9. Water su type: � /' � private public ❑ community ❑ spring ❑ � Cf e Are any wells on adjoining property?Ye No Q. If so, identify location: � Lot size: � . Directions to property: State Road #& Road — /U.f� -%�/�et S'%�6u I0. Type of structurelfacility: Propo : L�xisting: Q Type of dwelling: House: ❑ Mobile Home: Business: ❑ Type of business: Number of Employees: Number of bedrooms: � age Disposal? Yes ❑ atement? Yes ❑ N If so, # of basement fixtures: 6. Number of occupants or people�{o be served: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the PerSOri COUrity �Iealth DeParfinent for a site�esaaualic tion ahe �eite sewage disposal system for the above described property. I agree that the contents of t pp and represent the maximum facili[ies 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 De t. wi�hin 60 DAYS after the date of the evaluation of the site by the Health Dept., this application shall be�iyr e void and all fees paid forfeited. , gncc� Own r or uthorized Agcnt c . - 1 /, � Permit Issued ❑ Signature Date Permit Denied ❑ Plat Observed ❑ _. .r ,� � F CI'ORS�STIE EVALUAT70N : ; :;. s =, t: :.;; i �' � � ::zz�� i:,F: ,, dz. . . :: . !�� Z y �:,,,.�',� 7�"*. . s , �RF.h� s :'�, t'b S w.:> z. . �114r . „ �` ,_ � :,;i.:ii » xa .<.>.s! ......f.. -* . A .... ..:_: .� ka . ....... . I. SLOPE (%) S S S S PS ' PS PS PS U U U V 2 SOILTEXTURE(12-)6IN.) S S S ' S (SANDY.LOAMY.CIaYEY. N07E 2:1 CLA� PS PS PS PS U U U U ' 3. SOTLSTRUCilJRE(12•161N.) S S S S (MYEY SOILS) PS PS PS PS U V U V, 3. SpIi, DEPi}i (IN.) S S S S P$ PS PS PS U U U U S. RESTRICIIVEHORIZONS(TN.) S S S S (IMPERVIOUS STRATA. ROCK) PS PS PS PS U U U U 6. SOILDiWNAGF/GROUNDWATER S S S S (FJCTIItNAI. R II:iERNAL) PS PS PS PS U U U U �. SOA.PfltMEAB117TY S S S S (PEACOLAATION RA'[E) PS PS PS PS U U U U E. AVAILABLE SPACE S S S S PS PS PS PS U V V U 9. SffECLASSiFICATION(SE£HELOV'n SOIL SFAfES � S-SUITABCE PSPROYLSIONALLY SUiTADI.E U-UNSUTfABLE RECOMMENDATIONS/COMMENTS: - STTE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope patterns, etc.� C:V�MIPR0IDOCSUPPSEC.S�7 FINANCEPC �� '�'�y�,11 � � � ��a`� � � vel� � � a�`�a�-i c9-��J �', � 0 0 1' 0 � a w � a �I �i�� !� �� o � �-. G'. PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMI'ROVEMENT PERMIT B1614 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. Tax Map # A�/u Parcel # �3� Zoning Township ,�c� fR/to' Owner/Contractor ,�,7�o G��+ vn�n/ Date �� p7 Location/Address ��-� � T-� ��•r � �v�� -�—r �v.ti� sl� S.R.# ,,�� s Subdivision Name rt� T!� i�� PCA�.TATi ri-� Lot# �� SEWAGE SYSTEM SPECIFICATI�NS epair Lot Area � d/ ,4 cr Size of Tank /c`I�� C�q C, SFD Mobile Home ✓ Size of Pump Tank �c1/� Business # of Bedrooms� Nitrification Line �ice�'x3 � Max Depth Trenches Z-y '' Permits may be voided if site is al� Well and Septic Layout by_� Comments: ��'' r-r� x . ,t! �c�•✓-7�' �2 � .�, o ° Date �,L /,Q"- L Installed by� or intended use ged. by 'ell Permit Pai21�-7� WELL SYSTEM SPECIFICATIONS dividual `� Semi-Public Required Slab � �blic Replacement Air Vent t/ te Approved Required Well Log � ell Head Approved Well Tag � •outins� Annroved ✓ Comments: Date Installed by �-� fc f��C �� 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 eavironmental health specialist warrants that the septic tank system will continue to fuaction satisfactorily in the future or that the water supply will remain potable. c:\amipro\permit.sam O1/95 rev.l.l