A40 245«�. . .� �'
Person County Heaith Department
Sewage System Improvements Permit
Date: � �' • This Permit Void After 5 Y ermi #
�WI1CI: s�' 0. C. �i .� ��1 Y� 5 � t�rt P C1 r j'�# �
I.00BIIOD�D1teCIlOiLS:
i) 4'1 A, or^ �C,�..�
Subdivision Name: Lot #
Lot Size: � c• c ��' S— Type of Dwelling:
Water Supply: Private: 1,� Public: Community: �
Bedrooms: 2_ Garbage Disposal
Basement Basement Fix �
INFORMATI D BY
$��an: � ownet..o� aitative
REPAIR: REEVALUATION: 1
�
:
Size of Septic Tank: _� gallons Size of Pump Tank: �
Nitrification Line: 1�0 � �� 3 ' �
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemadve Syst�em: Conv. Pump LPP Pump i�,�
Remarks:
-------------------------
Date Well Approved� �� `� y� Well should be 100 f� from any sewer system
BY Sanitarian
Date S� Sy roved: – L�
BY '� Sanitarian
TIFT TE OF CO LETION
Contr�tor.
Sewage System location, installarion, 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 health hazazd. 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 or intended use change this pemtit is subject to revocation.
(G.S.130 A-335F)
Locatian of sewage disposal sewage system sketched on back.
(OVER)
�
NOT�: 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
5 '7 S �S
Person County Health Department �
Well Permit �
Date: 1� .�-�' �'This Permit Void After 3 Years
Owner: S� Gc y-� C�, ri c I%��r n s-��� �/ /S'7S �
Location/Directions: �-,
D� l�� 9r. ��ov�o
Subdivision Name: � �Rt #.,�
Drilling Contractor: �l
WELL CONSTRUCT'ION ►b
Distance from Nearest Property Line Distance from Source of r�,'
Pollution ;�.
Total Depth: FG Yield: � GPM Static Water Level FG �
Water Bearing Zones: Dept}� �t,�_ F� Ft. � i��
Casing: Depth From _�_ to G- FG Diame�er �O � Inches
TYPE: Steel Galvanized Stec2�
If Steel, does owner approve: �Y�� No
Weight: Thiclmess: �_� Height Above Ground: Inches
Drive Shce: Yes No
Were Problems Encountered in Setting the Casing? Yes No
ff "yes" give reason: � _ ,,'b�,
Grout Type: Neat Cement Concrete ;4
Annular Space Width �_ Inches
Water in Annular Space: Yes No
Method: Pumped Pres Poure�
Depth: From ��� co FG
IViaterials Used: No. Bags Portland Cement Weight of 1 bag
lbs.
� If mixture (sand, grave , cuttings) - Ratio: to _
ID Plates: Yes No ►d
4 x 4 slab Yes ,�_ No �
I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT I
THIS WELL WAS CONSTRUCTED ACCORDANCE WITH RE ULATIONS SET
FORTH BY THE PERSON COUNTY�.'�i�DEP/�TMEI�T. � ,
Sketch well location on reverse side.
Issued
Sanitarians Signature Date Completed
�i
NOTE: 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 located
at later date. Note location of water supplies on adjacent lots.
(1) ' (2)
�
PERSON COUNTY HEALTH DEPARTMENT
� � � 182
WELL AND SEWAGE SITE, LOCATION IlVIl'ROVEMENT PERNIIT
Tax Map #� t-h � Parcel #� 4��
Zoning Township �'.1�-1� d��-c}--e�
Owner/Contractor ,�, Date �l--S— 9S
Location/Address �n � .��-� � 1 � �'r�
� ` .R.# �j. 1 s�,��
Subdivision Name /.¢ Lot#
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SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area �� 39 �y Size of Tank /�r� l
SFD V Mobile Home�_ Size of Pump Tank �
Business # of Bedrooms � Nitrification Line �ov �,
Max Depth Trenches �S
�
Pernut Void after 60 months. Pernut Void if not in compliance with zoning regulations.
Pernuts may be voided if site is altered or intended use changed.
Well and Septic Layout by , � ' � � �-l/.�-e-(� ��� ;�
Comments:
Date y�-,� �S Installed by ' ' Approved by lf�.��Z� -�-c�-�-�-`
Semi-
Public
Site Appro
Well Head
Crrouting A
Comments:
Date
by
SYSTEM
�IFICATIONS
�uired Slab
Vent
�uired Well Log
ll Tag
Approve by.
This report is based in pazt on infoanation provided the homeowner or his/her representative in the application submitted for this percnit The
environmental health specialist is not responsible for false or misleading infocmation contained in the application. The envitonmental 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 ausleading
statements provided to him in the application Neither Person County nor the environme�al health specialist wazrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable.
ORIGINAL
c:�amipro�pemiitsam 01/95 rev.1.0
� . �
Site Evaluation Application
Fee Collected YES /
P� a► •� �433
�e �#� 1�I g!�
~" ' ►
Date: � � 3 —� �
2d0
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APPLICATZOId FOR IMPROVEMENTS PERHIT �� Mp ��� ��
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1. Permit requested by: owner��rospective owner:
. i �1 , „� � ii age� �
Address:
Home Phone �:
2. Name and address of current owner:
Business Phone 4�:
/�, . , ,
3. Property Description: Lot size: �}� .l�'�r�s
4
4. Tax map ��: Township: �S%� (��L
Subdivision Name: Lot ��:
5. Directions to pro erty: State Road �� & Road Names, etc.
.�—� � �,,,.-1-� T k P �'�41��' on l�v
� /ar �
- �D
6. Permit requested for: New Installation: Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served: �
8. Dimensions of Proposed Structure: Width: '7dL 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?
Rea1a� S��.x.,�e .���,e �!� w��-1ti �od�lo,r
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 No
Proposed: Existing:
Mobile Home: Business: _
Number of Employees:
Garbage Disposal? Yes I�o
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 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 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. 13 A 335(F)
'gned Owner or Authorizeci Agent
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Permit Issued
Permit Denied
Plat Observed
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i�ACTORS - SITE EVALUATION AREA 1 AREA 2 ARHA 3 AREA 4
1. SLOPE (�)
2 . S�li. TEXTUF2E ("12-36 in. )
(Sandy, loamy, clayey,
Note 2:1 clay)
3. SOIL STRUCTiJRE (12-36 in.
(Clayey soils)
4 . SOIL DEPTH (i.n. )
5. RESTRICTIVE HORIZONS (in.)
(Im�ervious Strata, rock)
. SOIL DRAI2dAGE/GROUNDWATER
(bcternal & Intetnal)
7. SOIL P�RMEABILITY
(Percolation Rate)
g. OTHER (specify)
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9. SITE CLASSIFICATION
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R F_CO�I�IDATIONS /COMMFSITS :
S:�:TE CLASSIFICATION DIAGRAH (Znclude: Soil areas, property lines. roads. streams, gullies,
Wet areas, fill areas. wells. water bodies, slope patterns, etc.)
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