A40 257. - - . �' , � .
• Sit� Evaluation Application
Fee Collected YES �
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Date:
C;Li7
APPLICATTON FOR IMPROVEMENTS PII2HIT
1. Permit requested by: owner� rospective owner: �1
agent•�p �
Address: �� � ��k a� e�5—O�!
Home Phone �,`� : Bus iness Phone �i :
2. Name and address of current owner: ���'�
�e,plac.e ,
� s;N �e �;de �,�,e
W� �ao��
>�orE G , �0.rke�r-
3. Property Description• Lot size: � �L.� e—
�-�=�---� .��o-a� 7 ,
4. Tax map 4� : ¢�� Township : �� 0.� � t V�'-�
Subdivision Name: Lot ��:
S. Direct,.i.ons to property: State Road �� & oad Names, etc.
n .�-4- t�1 � . �,. ,� \ a ► A ; l � C Y: � � I . N '7 � S >
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: Depth:
9. What type (if any) additions, expansions, or replacement is anticipated to the struc-
ture or facility that this sewa e disposal�syste is intended� o serve?
(� e Y� 10� C� S i_u c�\ e w�� w�-4-� � 0�-•b\ e w�� e /� i�-
10.
Water supply private? / public? _
Other source? (Specify):
Are there any wells on adjoining property?
11, Type of structure or facility:
Type of dwelling: House: _
Type of business:
Number of bedrooms: �_
Basement? Yes No
community? spring?
If so, identify location:
Proposed: Existing:
Mobile Home: '�' Business: _
Number of Employees:
Garbage Disposal? Yes ro
If so, number of basement fixtures:
12. Clearly stake a17. 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 Authorizen Agent
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Permit Issued
r' -
Permit Denied
Plat Observed
i�ACTORS - SITE EVALUATION AREA 1 AREA 2 AREA 3 AREA 4
S S S S
1. SLOPE (%) PS PS PS PS
U U U 7J
2. SGI7. TEXTURE (i2-36 in. ) S S S S
(Sandy, loamy, clayey, PS PS PS PS
Note 2:1 clay) U U U U
3. SOIL STRUCTtJRE (12-36 in. ) S S S S
(Clayey soils) PS PS PS PS
U U U U __
S S S S
4. SOIL DEPTH (in.) PS PS PS PS
U U U U
S. RESTRICTIVE HORIZONS (in.) S S S S
(Im�ervious Strata� rock) PS PS PS PS
U U U U
6. SOIL DRAIrIAGE/GROUNDWATER S S S S
(�cternal & Internal) PS PS PS PS �
U U U U
7. SOIL PERMEABILITY S S S S
(Percolation Rate) PS PS PS PS
U U U U
S S S S
g. OTHER (specify) PS PS PS PS •
U U U U
9. SITE CLASSIFICATION
(See below)
SOIL SERIES
S- Suitable PS - Provisi.onally Suitable U- Unsuitable
R F_COMMEEIIDATIONS ICOMMF�ITS :
S.�=TE CLASSIFICATION DIAGFtAM (Include: Soil areas, property lines. roads, streams, gulZies.
Wet areas, fill areas, c�rells. water bodies, sZope patterns, etc.)
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IN�ROVEMENT PERNIIT
Tax Map # �} � fj Parcel # � .S �%
Zoning Township r��`
Owner/Contractor %' C, P��. Date S- lf--%�
Location/Address �u.,Gc, . /S`7 -��� l �+ �fl .��-i'L
.R.#
Subdivision Name �' � c� Lot#
A0�16
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area %�'�-� Size of Tank 16r�-��-,��.�
SFD Mobile Home 1/" n l✓: Size of Pump Tank /��
Business # of Bedrooms 3 Nitrification Line 3�0 ��'l�siG�;�'1-*.-�y_
Max Depth Trenches `
Permit Void after 60 months. Permit 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 ` ,/;�%.t:�� .fl�c..c�-,...
Comments:
Date� �— R' � Installed by ���.,�f-o•,.. Approved by /v�s �.c.�,.-.-.
Semi
Site .
Well
Date
by.
SYSTEM
�quired Slab
r Vent
Required Well
Well Tag
by
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this pemtit 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 pro�ided to him in the application. Neither Person County nor the environmental health specialist watrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�pemvtsam O1/95 rev.1.0
ORIGINAL