A40 258� - �
Site Evaluation Application
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Date: `�� � -� �
Fee Collected YES NO
"'� 0.� �Ov �� � APPLICATT_OId FOR IHPROVIlKENTS PIItMIT
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1. Permit request�d by: owner/�rospective owner: �
1 agent:
Address : �`�- • � � a � 02 � ( �OX�
Home Phone �r: -(� 1.3 Business Phone ��:
2. Name and address of current owner:
3. Property Description: Lot size:
,� � c�, a,� �i
4. Tax map 4�:. Township:
Subdivision Name:
5. Directions_to
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i , o � -� �- res
r � o,�- � ; v �e�--
operty: State Road �� & +Road Names, etc.
v.�r� 1 e 1�A � 1� S`�d�
eoc� o r e i�o`�r� e�- ��
Lot ��:
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: v2 `i Depth: `l �
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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?
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: Proposed: / E isting:
Type of dwelling: House: Mobile Home: � Business:
Type of business: Number of Emp oyees: ,
Number of bedrooms: 3_ �E'arbage Disposal? Yes ro
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 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. 130A-335(F)
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Signed Owner or Authorized Agent
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Permit Issued l�
Permit Denied
Plat Observed �
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i�ACTORS - SITE EVALUATION AREA 1
1. SLOPE (�)
2. SGIL TEXTURE (12-36 in.)
(SandS, Ioamy, clayey,
Note 2:1 clay)
3 SOIL STRUCTIJRE (12-36 in.
(Glayey soils)
4• SOIL DEPTH (in.)
5. RESTRICTIVE HORIZONS (in.)
(Im{�ervious Strata. rock)
6. SOIL DRAIt1AGE/GROUNDWATER
A
(�cternal & Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
a �
S
PS
U
S
PS
U
S
PS
U
$
PS
U
S
PS
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PS
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PS
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AREA 2 ARF.A 3
S
PS
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PS
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PS
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$
PS
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PS
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PS
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PS
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PS
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PS
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U
$
PS
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PS
U
S
PS
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PS
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AREA 4
8. OTHER (specify) PS PS PS PS •
U U U U
9. SITE CLASSZFICATION
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R.ECOMMEENDATIONS /COMMEriTS :
S:�_TE CLASSIFICATZON DIAGRAM (Znclude: Soil areas, property lines, roads, streams, gullies,
We� areas, fill areas, c�ells. c�ate� bodies, slvpe patterns, ete.)
.. �
A 0317
PERSON COUNTY HEALTH DEPARTMEI�T
WELL AND SEWAGE SITE, LOCATION INIPROVEMENT PERNIIT
Tax Map #� �,D Parcel # a S g
Zoning Township F��.�' ��.
Owner/Contractor �'�,��-c�e_ /n�-r/.��.. Date S 5 _ ��" ,
Location/Address / �. `
S.R.# 1 ` ,� .y�s�'��l
ubdivision Name � z:.�—�' " Lot# �
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area �� D S��s Size of Tank_/�-
SFDJ/` Mobile Home , , Size ofPump Tank /
Business # of Bedrooms .3 Nitrification Line t D cr 'X3 �
Max Depth Trenches • 2..� ,
Pernut Void ai�er 6U months. Permit Void if not in compllance with zoning regulations.
Pernuts may be voided if site is alter�d or intended use changed.
Well and Septic Layout by 1y.,�+�� ,���.
Comments:
Date
Installed by S�, S�{'P�-F Approved by.
idividual Semi-
ublic Repla
ell H d Approved.
�outi g Approved_
Da
WELL SYSTEM SPE IFICATIONS
ublic quired Slab
ement 'r Vent
equired Well Lo� _
Well Tag
by Approv d by.
This report is based in part on infortnation provided the homeowner or his/her representative in the application submitted for this pennit 'Ihe
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 Uus report that may have resulted from false or misleading
statements provided to him in the application. Neither Person County nor the endvonmental health specialist wazrants that the septic tank system will
continue to fundion satisfadorily in the future or that the watet supply will remain potable. c:\amipro�perrtrit.sazn O1/95 rev.1.0
ORIGINAL