A40 256PERSON COUNTY HEALTH DEPARTMENT
SEWAGE DISPOSAL
IMPROVEtiENTS P • IT O.
Issue Date:
� �` c
Owner:
Location:
Septic Tank Contractor:
Building Contractor:
Water Supply: Private Public
All wells should be 100 ft. from sewer system.
Lot Size: f �{C,_
Sevage Disposal Facilities: No. bedrooms
Size of tank: ���i �Qw� Nitriyic
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protectiion 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 a 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 CO. HEALTH DEPARTMENT STAFF flEFORE
ANY PORTION OF THE INSTALLATION IS COVERED AND PUT TO USE. THIS
PERMZT VOID AFTER 3 YEARS.
Date Well Approved: - Signed � ��C
By: Sanitarian
Date Sewage isposal Ap r ved:_
� �� �Z�Q� Counter- �
By: /�� signed
(O er ' his representative)
Certificate of Completion
Date Approved:� /_ l�� � ��
Sanitarian
(Over)
Location of well and sewage disposal facilities sketched on back.
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Person County Health Department
' � Well Permit
DATE ISSUE : • DATE. DRILLED:1j�. � ,��COUNTY: � �r-6' c� �_
OWNER: � c {9{} ^ „( .S� , �-h ROAD/STREET:
ADDRESS:
DRILLING CONTRACTOR: r/ n S Wi /J ��V
NAME ADDRESS
WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollution %� � �
Total Depth:J Q 3 Ft. Yield• � GPM Static Water Level Ft.
Water Hearing Zones: Depth Ft�_Ft.��t. Ft.
Casing: Depth: From n to1��Ft. Diameter: !i � Inches
TYPE: Steel Ga van' Steel
If Steel, does owner approve: Yes No
Weight:' -�Thickness: I�YHeight Above Ground:�Znches
Drive Shoe: YesCd�_H /.��t�o
Were Problems Encountered in Setting the Casing? Yes_No �
If 'yes' give�son:
Grout: Type: Neat Sand/Cement Concrete
Annular Space Width � Inches
Water ia Annular Space: Yes No �—
Method: Pumped Pressu�r,e Poured �-�
Depth: Fzom �to d Ft.
Materisls Used: No. Bags Portland Cement�Weight of
1 bag�lbs.
If mixture (sand, gravel, cuttings) - Ratio:�_to�
ID Plates: Yes v No
4 x 4 slab Yes� No
DRILLZNG LOG
De th
F;om To Formation Description
LL �
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I HEREBY CERTIFY THAT THE ABOVE IN£URMATION IS CORRECT AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE W7TH REGULATIONS SET FORTH BY THE
PERSON COUNTY BOARD UF HEALTH. PERMIT VOZD AFTER THREE YEARS.
� S,u.� t . �a-s-�''�f
Siqna e of Contractor Data
�l-� -
Sanitarian's ignature Date Issued
Sanitarian's Signature Date Completed
Sketch well location on reverse side.
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The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT No.
_/ Date � ^
Owner: �j P G v b vP � v ��!� �-
Location:
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U G1 D .r, . ` � r! ,� . :F
Contractor:
Water Supplp: Private Public
10'�`�`
Sewage Disposal Facililies: No. bedrooms Dishwasher, Disposal,
washing machine, other
Size of tank: /r>%
Other disposal facility:
� appliances �
Nitrification line: —�"
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
5eptic tank should be pumped out every 3 to 5 years and shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
Date approved: Signe
/ t� '��.�-
Sanitarian
Well:
Sewage Disposal: I Counter- l,C9L,tl���4�1+�-
aigne
BY� (Owner r his representative)
Certilicate of Complelion _
Date Approved: ��By:
a itarian
(OVE
Location of well and sewage disposal facilities sketched on back.
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Site Evaluation Application
Fee Collected YES �/
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1. Permit requested by:
Address:
Home Phone ��:
rI ' 1
Date: � - � - � �
�0 � .e 1 aCe
�� i � 1e v.� i o� e JU 1�-
APPLICATTON FOR IHPROVaiENTS PERHIT W� Si �, e
��Ji�
�prospective owner: �
agent:
i3o X �t 1 l�.oxba
2. Name and address of current owner:
3. Property Description: Lot size:
��
4. Tax map ��: �-�'0 �a Township:
Subdivision Name:
Business Phone �r:
SaJ�J,. -�.
� 10.�- i ; V e�-
5. Directions to property: State Road �� &
�1 �� \� v��rr�,1 e�ul � 1 � S i
ad Names, etc.
0
Lot �t:
6. Permit requested for: New Installation: Repair:
Additional Renovation re-using present system:
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YiC-�J�� �
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?
�R P,01 a� a S� � � �� i P_ u.�� d� e__�� 1� vJ ���r— S i�c� 1�
10. Water supply private? �� public? _
Other source? (Specify):
Are there any wells on adjoining property?
community? spring?
If so, identify location:
H
H
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x
11, Type of structure or facility: Proposed: Existing:
Type of dwelling: House: Mobile Home: Business:
Type of business: Number of Employees:
Number of bedrooms: �_ Garbage Disposal? Yes No
Basement? 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 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 m�ximum 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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Signed Owner or Authorized Agent
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Permit Issued
Permit Denied
Plat Observed
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i�ACTORS - SITE EVALUATION AREA 1 AREA 2 ARF.A 3 AREA 4
1. SLOPE (X)
2 . SGIi, TEXTURE (i2-36 in. )
(Sandy, loamy, clayey,
Note 2:1 clay)
? SOIL STRUCTURE (12-36 i.n.)
(Clayey soils)
4• SOIL DEPTH (in.)
.5. RESTRICTIVE HORIZONS (in.
(Impervious Strata, rock)
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SOIL DRAI2IAGE/GROUNDWATER
(F�cternal & Internal)
SOIL P�RMEABILITY
(Percolation Rate)
8. OTHER (specify)
S
PS
U
S
PS
U
S
PS
U
$
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
$
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
$
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
9. SITE CLASSIFICAT70N
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
RECOt�NDATZONS /COMMF�TS :
S
PS
�T
S
PS
U
S
V$
U
$
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S:�:TE CLASSIFIGATZON DIAGRAM (Include: Soil areas, property lines. roads, streams, gullies,
Wet areas. fill areas, wells, water bodies, slope patterns, etc.)
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMI'ROVEMENT PERNIIT
Tax Map #� �. d Parcel S�
Zoning Township �.��'`' °
Owner/Contractor '7�� � . �.,,- -��. Date S- � - p�"
Location/Address / .�'7 X�a��r��, .�� .����',c►���,2
A0�15
S.R.# l S 7-��-�sti
SFD v
SEWAGE SYSTEM SPECIFICATIONS
Lot Area �.r�c�
Mobile Home �/ �lJ.
# of Bedrooms �
Size of Tank�
Size of Pump Tank.
Nitrification Line
Max Depth Trench�
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,��� C r-u-c-� �.�,,..�
Comments:
Date� �- �j.� Installed by " ` Approved by GJ .,i.e� ��-�-�-+�-
` ' WELL SYS
Individual Semi-Public
Publi _ Replacement
Site Ap fo. ed
Well Hea Approved
Groutin Approved
�o nts:
�at Installed y
SPECIFICATI N�
Required Sla _
Air Vent
Required Vy 11 Lo�
Well Tag
Approved
This report is based in part on information provided the homeowner or his/her representative in the application submitted for ihis pemiit. The
environmental health specialist is not responsible for false or misleading infortnation contained in the application The environmental health specialist
is also not responsible for concealed conditions on the property or for statecnents in this report that may have resulted from false or misleading
statements provided to him in the application Neither Person County nor the environmental health specialist warrants that the septic tank system will
continue to function satisfadorily in the future or that ihe water supply will remain potable. c:�amipro�pemutsam O1/95 rev.1.0
ORIGINAL