A40 239z
_. P�r��n County Health Department �
Sewage System Improvements Permit
Date: - Z U"��I'f»s Permit Void After 5 Years Permit #
Owner:_�a.ra'�e Wc,r�d..� SR# /S7 � •
Location/Directions: C
Subdivision Name:j= f��- r�•�--- ,%�f��%-�
Lot Size: �ti �- • Type of Dwelling:
Lot
Water Supply: Private: " blic: Community:
Bedrooms: � arbage Disposal
Basement Bas�ment Fix s
INFORMATION GERTIFIED BY
$aI11tST18i1 � ' ' � � ..^�... owner or repres ve /
REPAIlt '�`%f ''REEVALUATION: �
Size of Sepac Tank/�"U"� gallons Size of Pump Tank:
Nitrification Line: � � a� 3'
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks:
-------------------------
Date Well Approved:
BY
Bte Se ge y m
Well should be 100 fL from any sewer system
Sanitarian /
�-zs-�
!�` Sanitarian
U- - �ERTIFTCATE OF COMPLETION ,.,,,3
Contractor. 1� �
------------------------- y�
�
Sewage System location. installarion, and protection must meet state and local �
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 health hazard. Septic tank and
nitrification line must be inspected and approved by a member oF the Person County
Health Departrnent before any portion of the installation is covered and put into use. If
the site pians or intended use change this permit is subject w revocation.
(G.S. 130 A-335F)
L.ocation of sewage sal sewage system sketched o�t back.
�,�.,,.�a�- if-,� t n � ��.,�-• � .�(7'-----
(O�ER) %
N07'E: Make sketch of installation showing lot size and shape, location oi house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
_. ,...,._ a.,.,, ,s ..... ........:.... „� ...e.o� �..,,.,�:o� ,... fl,�:".o..+ i.,•� • -
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_:___ ___�-' _. _ _ . p ��,� �'-�j°v. �� y� �/�
��� ����� �� ��
� ealth De artment '�
� •.�e�so County p �
,j����� Weil Permit �
Date: '�.YJ�- � V n '�
Owner: SR# �� e,.4�
lAh�[I��lyL�i' LL��. .r
lAh. I �
Subdivision Name: � �k "^ #
Drilling Contractor:
WELL CONSTRUCi'ION ►�
Distance from Nearest Property Line Distance from Source of �'
Pollution �
Total Depth: G reld: �� GPM Static Water L,evel Ft �
Water Bearing Zones: Dept�, _/FG�Ft. ��(��;'G
Casing: Depth: From �_ to V FG Diame O{ r Inches
TYPE:
GrouG
I HERE]
THIS W
FORTH
Steel � Galvazuzed Steel
If Steel, does ownei approve: No
Weight: Thiclmess: Height Above Ground: Inches
Drive Shce: Yes No
Were.Problems Encountered in Setting the Casing? Yes No
"d
�
If "yes" give reason•
Type: Neat S ement Concrete
Annular Space Width Inches
Water in Armular Space: Yes No �
Method: Pumped Press Potiued
Depth: From �� to Ft
Materials Used: No. Bags Portland Cement Weight of 1 bag
f[:�
If mixture (sand g���ttings) - Ratio: _
Sketch well location on reverse side.
( �mprovement Permit
1. Permit requested by:
Address : /cJ� 4' �fD-�
APPLICATION FOR:
( ) Subdivision
2. Name and address of current owner:
•r
Date Received:
z
( ) Other �
Home Phone ��0.3 �6�
Business Phone ��
3. Property Description: Lot size ��0 Dimensions:
Front Left Right Rear
`-`c�- • � = //i
4. Tax map No. Township: Block No. Lot No.�
5.
6.
7.
8.
9.
10.
11.
H
Directions to property: State Road No. & Road Names, etc. �
� �
/lJ /h �
�
P�rmit requested for: New Installation � Repaired �
Additional Renovation re-using present system
Number of occupants of people served_
Dimensions of Proposed Structure: Width Depth
H
What tyge (if any) additions, expansions, or�replacement is ani.icipated X
to the structure or facility that this sewage disposal sys�em is intended a
to se�-ve? '�
. �
d
`
Type of water supply: Well yes no: If ao, name source of water "p
supply: Are there any wells on adjoining ��
r
property? If so, identify location. �
`-'� �i �� �_ �
i
Type of structure or facility: Proposed Existing -�
Type of dwelling: Ho�se Mobile Home Business �
Type of business Number of Employees
Number of Bedrooms� Number of automatic appliances
Basement Number of basement fixtures �
0
0
12. Clearly stake all corners of the property snd the corners'of all proposed x'
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 conten
of this application are true and represent the maximum facilities to be
placed on the property. I understand that if any changes are made without
approval from the Person County Health Department, the permit will be void
Any permit for a system is non-transferable without prior approval of the
Person County H�alth Department. Permits are valid for� months from dat
of issue.
� \
SIGNED
FACTORS - SITE EpALUATION
l. SLOPE (X)
2. SOIL TEXTURE (12-36 in.)
(Sandy, loamy,.clayey,
Note 2:1 clay)
3. SOIL STRUCTURE (12-36 i.n.
(Clayey soils) �
4. SOIL DEPTfi (in.)
S. RESTRICTIVE HORIZONS (in.
(Impervious Strata, rock)
6. SOIL DRAINAGE/GROUNDWATER
(�cternal & Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
AREA 1
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS .
U
S
PS
U
S
AREA 2
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
r
AREA 3
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
P3
U
S
8. OTHER (specify) PS PS PS PS
� U U U U
9. SITE CLASSIFICATION ---
(See below) '
SOIL SERIES --
S- Suitable PS - Provisionally Suitable U- Unsuitable
RECOMMEENDATIONS/COMMENTS: '"
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies,
wet areas, fill.areas, wells, water bodies, slope patterns, etc.)
AREA 4
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S