A40 285.
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_ Bacteria � _ Chemical
l. Permit requested by: .
�wner/prospective owne:/agen
Address: • n �l
_ PetroIeum � _ Pesticide � _ L�ad
�S 7. Dimensi s o P aposed Structure:
�-- `� Width:
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Depth:
� J� �� � � S. What type (if any, additions, expansions, or
��-� �'� �7��-3--- re pIacement is antici pated to the stcucture or facility
that this sewa;e disposal system is incended to secve?
ome Phone �: p� (Q�J �
usiness Phone tt:
Name and address of current owne;: 9. Water suppl 5•pe:
�,�f�/J� C _ private ublic ❑ cor,ununity ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No�
Q __ If so, identify location:
Property Description: L,ot size:
. Tax Map#: -
Parcel#:
Township:
. Directions to propercy: State Road n& Road
I�Iumber of occupants or people to be served:
10. Type of structurelfacili[y: Proposed: ..isting: Q
Type of dwellina•
House: obile Home: � Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: _���-�..��
Garbage Disposal? Yes o �7
Basement? Yes ❑ No �f so # of basement fixtures:
CLEARLY STAiLE ALL CORNERS OF THE PROPERTY AI�ID THE CORNERS OF ALL
PROPOSED STRUCTUR.ES.
I hereby make application to the PersOn COunty HCalth Department for a site evaluation for the on-site
sewage disposal system for the above deseribed property. I agree that ttie contents of this application are tcue
and represent the maximum facilities to be placed on the property. I understand if the site is altered oc the
intended use changes, the permit shaIl become invaIid. I understand that before an Improvements Permit can be
issued, I must present a sucvey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Hcalth Dept., this applica�on shall become�voi and all fees paid forfeited.
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Signecl Owne� or�Autt�orized Agent
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��.,P S/s��� B 2964
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # � �� Parcel # ��.°� S
Zoning Townshi
Owner/Contractor ' ,,, ' Q i� Date 7- / 2-�Q
�. � ,�
Location/Address � o� a�* ���.� / �� /y �^� �
nosl ��,�.. �N 1,��' . S.R.
ision Name
Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area l• GD �c . Size of Tank /ODU
SFD ✓ Mobile Home Size of Pump Tank /lJDO
Business # of Bedrooms 3 Nitrification Line �S/0�0'�3
Max Depth Trenches i8 "
Permits may be voided if site is
Well and Septic Layout by ,t c
Comment : S�� G'o�,�; ;�
��%'r� L-�iys �� �
Date Installed by_
intended use changed.
�
Approved by.
Well Permit Paid � WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab �1-i I('S-'o:�
Public Replacement Air Vent �(' �'o�
Site Approved_ Required Well Log =(
Well Head Approved 3+-I 1 I-S�o,�t Well Tag i% 3�-{ (1-5" 'oZ
Grouting Approved � Z-�2 `�as �� b 3�t I I� s-o�
Date
This report is based in part on information provided the N'jbmeowner or his/tier
representative in the application submitted for this permit. 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 provided to
him in the application. Neither Person County nor the environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
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Tax_Map #: "1�� . Parcei #: ���
Zoning: Townshlp: '
SUbdivision: Section: Lot:
Appllcant• � - �
Location: ��1�� �1�ITe� ` _
e
operation Perrn it
Sysiem Type (in Accordance With Table Va):
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEIIVAGE TREATMENT AND DISPOSAL,
AND ALL C NDITIONS OF T IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORI N. �� ���.�
. ! �� � �a
thorized State Agent Date
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Date: I C� [_
Owner:
Location/Directions:
Subdivision Name:
Drilling Contractor:
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG '
Lot #
WELL CONSTRUC'I'ION v
Distance from Nearest Property Line I v Distance from Source of
Pollution t G �
Total.Dep.th: 1�U FG Yield: � C% GPM Static Water Level a.S" Ft.
Water Bearing Zones: Depth ,� �O F[. t O Ft� F� Ft.
Casing: Depth: From 6 to (�Z Ft. Diameter: Inches
TYPE: Steel - Galvanized Steel
If Steel, does owner approve: Yes No
Weight: Thickness:� '� Height�Above Ground: /� Inches
Drive Shoe: Yes ✓ No .
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" give reason:
G.rout: Type: Neat Sand/Cement / Coricrete
Annular Space Width - Inches
Water in Annular Space: Yes No
_ .. Method: Pumped . _ Pressure Poured � - �
Dep[h: Fr�m O to � C� Ft.
MateriaLs Used: No. Bags Portland Cement Weight of .l bag lbs.
If mixture (sand, gravel; cuttings) - Racio: to
ID Plates: Yes � No � �
� 4 x 4 slab Yes � No
I HEREBY CERTIFY THAT THE ABOVE INFORM�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSO� C^v'vi�TY HEALTH DEPARTMENT.
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Si nature of Contractor Datc
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