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A40 238�` Person County Health Department Sewage System Improvements Pe�mit Date: � � 13 i - r- D ��¢ permit Void ter,� xears Permit # Owner: Y t/-lC� 9�t%,�.��'� �.!'� U�� SR# !S"% S ubdivision Name: ��- /Cq. l J� t V�ri /"l � r, � l'�:.�,ot #� Lot Size: , Type of Dwelling: Water Supply: Private: _�'� Public: Community: Bedrooms: �_ Garbage Disposal Basement Basemep ix INFORMA BYU�- SSTIiiStian: owner or tep � e REPAIR: REEVALUATION: Size of Septic Tank: � gallons Size of Pump Tank: Nitrification Line: — �� (' � � Depth of Stone: 12 u�ches Max Depth of Trenches: Altemative System: Conv. Pump LPP Pamp Remarks: Date Well Approved: �'" �`�"9-3 �Well should be 100 ft� from any sewer system BY Sanitarian Date Sewage System Approved: s' 2- 9 3 BY ��9 ��_ Sanitarian CERTIFTCA'T� OF COMPLET'ION � ,� Conaactor. i�oNN,'c L��,��.�,� /'% e,�� S. % s%B / yZ _ /aav,�a l — — — �- �_ 9.� 0�= aw r.,k � Sewage System location, installarion, and protection must meet state and local � reguladons. Septic tank shouid 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 nitrification line must be inspected and approved by a member of the Person County Health Department before any portion of the installation is covered and put into use. If the site plans ar inter�deci use change this pemiit is subject to revocation. (G.S. 130 A-335F) Location of sewage disposal sewage system sketched on back. �� , �- /-E � �ov�.� �� v�-�- NO'1�: Make aketch of installation showing lot size and shape, location oi house, septic tanks, privies, water syipplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located r at later date. Note location of water supplies on adjacent lots. �(1) (2) v' ��L�y I�u�T� R P�rson County Health Department Well Permit Permic o��: SR# I's Subdivision Name: � �� cr� Lot #� J 5— F-) Drilling Contractor. 1 I M SO�U L�iC WELL CONSTRUCi'ION Distance from Nearest Praperty Line Distance from Source of Polludon Total Depth: FG Yield: !� GPM Stetic Water I.evel FG Wtuer Bearing Zones: Dept� ��Ft. F�C7�(,�Ft. Casing: Depth: From (� to FG Diameter: �J�_ Inches TYPE: Steel Galvenized Steel If Steel, does owner approve: Y No Weight: Thicla►ess: � Height Above Ground: Inches Drive Shce: Yes No Were Problems Encountered in Setting the Casing? Yes No If "yes" give reason• � Grou� Type: Neat � S d/Cement Concrete Annular Space Width � Inches Water in Amiuler Space: Yes No Method Pumped Pres Poured '� Depth From _�,_ to Ft Materials Used: No. Bags Portland Cement Weight of 1 bag lbs. If mixture (sand, gravel, cuttings) - Ratio: to ID Plates: Yes ✓ No 4 z 4 slab Yes `� No I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT 'THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTTH REGULATiONS SEI FORTH BY THE PERSON COUNTY H EP NT. 3L`iq3 S' of tor Date �/rI� 3 'tatian's Si attue Date Issued Sanitarian's Signanue Date Completed Sketch well locadon on reverse side. z � � ��I a�..% g��4 � , ,e �� a w � a Improvements Permit (Established/Recorded Lot) Pernut (Unrecorded Lot) Permit (Mobile Home Replace) Improvements Permit (Addition) _ Bacteria i � -�a - �� Reinspection of Existing System (Loan Closing) Repair/Replace existing Septic System Permit for New Well _ Replace Existing Well _ Chemical � _ Petroleum � _ Pesticide � _ Lead 1. Permit requested by: 7. Dimensions or Proposed Structure: � owner/prospective owner/agent:,1►/1�� sve f C/9 y�Ah Width: �� e �� S� N ��I� ddress: O " �/ r . De th: �� W i �e- M � �'`�' `� ,�-j � 3 r1i, c. 2, � p o,Y ho d • C= 2�S g, 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 #: 5 i 9- S 7 3 8� usiness Phone #: .So 3 - /%�'7 2. Name and address of current owner: 9. Wate�r su ply type: S9 .n .� private LJ public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No ❑ If so, identify location: 3. Property Description: Lot size: l� Z_S . Tax Map#: fi �/ d� 10. Type of structure/facility: Proposed: xisting: ❑ Parcel#: ��R Type of dwelling: Township: �/9 � %� ; v-e ✓ House: �Iobile Home: �Business: ❑ 5. Directions to property: State Road #& Road Type of business: Number of Employees: ames, etc. Number of bedrooms: 3 S S o c� l, Garbage Disposal? Yes ❑ No ❑ Basement? Yes ❑ No ❑ If so, # of basement fixtures: 6. Number of occupants or people to be served: Z CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the PersOn COunty Health Depal'tment for a site 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. 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 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. �� . ,�i , � � Signed Owner or Authorized Agent � , . •r Permit Issued ❑ Signature Date � � � '� Permit Denied ❑ Plat Observed ❑ FACPDRS-51'IEEYALUATiQN ' AREA1 AREA2 :: AREAi3 AREA4 ::: _. _ _ 1. SLAPE ( k) S S S S PS PS PS PS U U U U 2. SOQ. TEXNRE (12-36 iN.) S S S S (SANDY, LOAMY, CLAYEY, NOTE 2:1 CLAI� PS PS PS PS U U U U 3. SOTI. S7RUCiL1RE (12-361N.) S S S S (CLAYEY SOiLS) PS PS PS PS . U U U U 4. SOIL DEPIH (IN.) S S S S PS PS PS PS U U U U 5. RESTRICTIVE HORIZONS (IN.) S S S S (IMPERViOUS STRATA, ROCK) PS PS � PS PS U U U U 6. SOIL DRAINAGFIGROUNDWA7ER S S S S (IXTERNAL & IN7ERNAL) PS PS PS PS U U U U 7. SOIL PERMEABILITY S S S 5 (PERCOLOATION RATE) PS PS PS PS U U U U R. AVAII.ABLE SPACE S S S S PS PS PS PS lJ U U U 9. SITECLASSIFICATION(SEEBELOW) SOiL SERIES S-SUITABLE PS-PROVISIONALLY SUITABLE U•UNSUITABLE RECOMMENDATIONS/COMMENTS: SITE CLASSIFICATION DIAGRAM (Include: 5oi1 areas, property lines, roads, streams, gullies, wet areas, iill areas, wells, water bodies, slope patterns, etc.) C:WNIPRO�DOCSIAPPSEC.SM FQVANCE.PC M � � � � U i.. C� a � r .r O V V O PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Tax Map # �' � � Parcel # a..�8�' Zoning Township �--�-P"�' �� Owner/Contractor ��`'�-._: � ^Date Il --Z 1 9S � Subdivision Name ��--i'" �-�-� ` Lot# /-� �I Layout p � � i �3 �+�� ` -� �, �, .� �- //��J 1 � ��,� r / `7. C7 B� K iJ /� eJ�'�KJ��+c.- (% � I'LI , � 1 � l � � .2-�Q�� / r .R.# ` . !.r'� d�c� As Installed s. �rJ �r. A% f--�•� � �� ' ��'yih, �.�=-, ��---� _ ' _ . SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area 7-.�5��—�� Size of Tank %B��' SFDr/` Mobile Home � Size of Pump Tank y��i Business # of Bedrooms � Nitrification Line `�o� �X 3 Max Depth Trenches�� Permit Void after 60 months. Permit Void if not in compliance with zoning regulations. Permits may be voided if site i alte�red or intended use changed. Well and Septic Layout by �� -� � �— ��'� � � Comments: � � Date ��—a /-` � � � Well Permit � H Individual Public S ite Approve Well Head A Installed by ��..��-+^ Approved by WELL SYSTEM -Public Installed by CATIONS Required Slab _ Air Vent Required Well Log Well Tag i�� This report is based in paR 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 informafion contained in the application. The environmental health specialist is also not responsible for concealed condifions on the property or for statements in this report that may have resulted fmm false or misleading statements provided to him in the application. Neither Person County nor the environmental health specialist wazrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:\amipro\permit.sam 01/95 rev.1.0