A40 81u
0
�
. u�
cn
�
� � � ' •
The District Health Department
Orange, Person, Caswell, Chalham, Lee Counties
Water- Supply and Sewage Disposal
Date � � ^� .^ / S
Owner: � -'
Location•
� �
Contractor: �'� �
Waier'Supply: Private Public •
. ..1; ', ,
Sewage Disposal Facilities:
washing machi e, o r i
Size of tank:
Other disposal facility:
/
rooms Dishwasher, Disposal,
� appliances
�/ 7 �/
Nitrification 1�nP� � /i r>
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Above recommendations based on information received and observed
soil condition. Septic tank and nitrification line MUST BE INSPECTED
AND APPROVED BY A MEMBER OF THE DISTRICT HEALTH DE-
PARTMENT STAFF before any portion of the installation is covered
and put into use. �
Date approved:—
Well:
Sewage �D s �al:
By. .. � .i
;�
� ` A
��� �ERTIFIC �
�
`7 � ( r
_��_ Signe
" 'It►e Distric
O � '
!
. y
(OVER)
�Ywt`X-�����
Health Department
Location of well and sewage disposal facilities sketched on back.
NO� Make sketch of installation showing lot size rrti hape, location of house, septic tanks, privies, water
supplies, eta Note special problems existing on lot. . it in�measurements in order that installations may be located
at later date. ' `�
' �-
�
� • .
' Person County Health Department �
Well Permit �
Date::� _�- �3 This Permit Void After 3 Years ' I
Ovmer: I�v� c� rl I�c� � SR# �_
Location/Direcdons:
Subdivision Name: � Lot #
Drilling Contracwr.
W�i.t CONS'I'RUCi'ION
Distance from Nearest Praperty Line Distance from Source of
Polludon
Total Depth: Ft Yield: �� GPM Static Water Level FG
Water Bearing Zones: Depth Fst�� Ft. ' FG �
Casing: Dept}►: From � 1_ F� ��ety Inches
TYPE: Steel Galvanized Steel✓
If Steel, does owner approve: No
Weight: Thiclatess: Height Above Ground: Inches
Drive Shce: Yes No
Were Problems Encouncered in Setting the Casing? Yes No
If "yes" give reason:
Grout: Type: Neat S ement Concrete
Annular Space Width Inches
Water in Arinular Space: Ycs No
Method: Pumped Press}i� Poure�
Depth: From _� � .�(yL-- F�
Materials Used: No. Bags Pordand Cement Weight of 1 bag
lbs.
If m'vccure (sand, gravel�uttings) - Ratio: co
ID Plates: Yes No
4 z 4 slab Yes —�— No
I HEREBY CER'I'IFY THAT THE ABOVE INFORMATION IS CORRECf AND THAT �
'fHIS WELL WAS CONSTRUCTED IN CCORDANCE WITH REGULATIONS SET ,.,;
FORTH BY THE PERSON COUNTY H ���� � I�i' I�� I�
.�
3/� 3
Sanitarians Signature Date
Sanitarians Signature Date Completed
Sketch well location on reverse side.
Site Evaluution Application
Fee Collected YES /
g� 011 •� v� �q 6
Q.e �
�i�
Date:
APPLICATTOId FOR IMPROVII`iENTS PERHIT
1. Permit requested by: owner/�ros�ective owner: /�,
gent/% � T
Ad d r e s s : / �. S � �a-vu,� ! -c�i,t �«-n.f" -�,��
Home Phone ��: �y �/� 3� / s Business Phone �i:
2. Name and address of current owner: ��„�,�rr C` ��r -.
3. Property Description: L�t size: ���a '�L��
�
4. Tax map ��: I`t ��fg I Township: �US��/ �r�
Subdivision Name: _�� Lot ��:
5. Directions to property: State oad �� & Ro d Names, etc.
r^ ,�.- /� % / / !1 /i _ T_, . . . �� o ��.. i�
�2 -3 -9�
� �a�'�'� J0.Y�o'�
�- � � p„�.ci.� ��
» �drov µ
6. Permit requested for: New Installation: Repair:
Additional Renovation re-using present system: �
7. Number of occupants or people to be served: _�
��a��X.� � l.
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?
OV GN -� � Aa�i_►�c� a c��c�� �- ex p a� d�►�,1,� 1� ec� �rooM
10. Water supply private? (� public? _
Other source? (Specify):
Are there any wells on adjoining property?
11,
yp - cture or facility:
Type of dwelling:
Type of business:
Number of bedrooms:
Basement? Yes No
community? ____ spring?
Proposed:
Mobile Home:
Garbage Dis ' Yes
If so, number of baseme
If so, identify location:
Existing:
_ Business: _
Number of Employees:
ro
�ures:
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 maximum facilities to be placed on the property. I understand if
the site is altered or the intended use changes, the permit shall b@ome invalid.
Permits are valid for 60 months from date of issue. Permission i ereby granted to
enter the property for the evaluation. G.S. 1 A- 35(F)
Signed Owner or ori
�
� . � - ,; . . , .,
Permit Issued
Permit Denied
Plat Observed
i�ACTORS - SITE EVALUATION AREA 1 AREA 2 ARFA 3 AREA 4
S S S S
1. SLOPE (�) PS PS PS PS
U U U 7J
2. SGIL TEXTURE (i2-36 in. ) S S S S
(Sandy, Ioamy, clayey, PS PS PS PS
Note 2:1 clay) U U U U
? SOIL STRUCTIJR.E (12-3b in. ) S S S S
(Clayey soils) PS PS PS PS
4 . SOIL DEPTH (i.n. )
5. RESTRICTIVE HORIZONS (in.
(Im{�ervious Strata� rock)
6. SOIL DRAIIQAGE/GROUNDWATER
A
(�cternal & Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
s`
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
s
U
S
PS
U
S
PS
U
S
PS
U
S
PS
u
s
U
S �
PS
U
S
PS
U
S
PS �
U
S
PS
U
s
$. OTHER (specify) PS PS PS PS •
u u u u
9. SITE CLASSIFICATTON
(See below)
SOIL SERIES
S- Suitable PS - Provisioaally Suitable U- Unsuitable
R ECOt�2�IDATIONS / COMMENTS :
S.�TE CLASSIFZCATZON DLAGRAH (include: Soil areas, property lines. roads, streams, gullies,
Wet areas, fill areas, c�ells. water bodies, slope patterns, etc.)
r " " .
A 0055
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT PERNIIT
Tax Map # /q�� Parcel # /
Zoning Township �,, F u.
Owner/Contractor � Date 2 -6 -
Location/Address �
S.R.# // D
Subdivision Name
.
� � �
i�' - '✓ t ,
�!.� , -
� , s-
Lot#
as �i�ea
�il
� / S'
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area �•- �o?�¢ Size of Tank /�d�o C ' `,
SFD �� Mobile Home �/' Size of Pump Tank /Y�._
Business # of Bedrooms_�_ Nitrification Line �. �r0 �X 3'L�*��
Max Depth Trenches '
Pernut 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 lcJ -t e-e ,���w� ��'"`��
Comments:
Date �-�-�'!S Installed by - � � ___Approved by �/�'� .���,...
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this pemut The
environmental health specialist is not responsible for false or misleading infonnation contained in the application. "Il�e 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 envuonmental health specialist wazrants ihat the septic tank system will
continue to function satisfactorily in the future or that the watet supply will remain potable. c:�amipro�pemut.sam Ol/95 rev.1.0
ORIGINAL
�
�
..-__—
. _p ,
PERSOl COUNT EALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT PERNIIT
Tax Map #� �� Parcet # g` f
Zoning Township ���, _ J=�-z.�.
Owner/Contractor rj •�L.¢� Date -! g- 9s
Location/Address ; 1e,.1 ..�c'ti.,� a � `
i ` l S.R.# 1 l 5E- o
. � •�
SEWAGE SYSTEM SPECIFICATIONS
air Lot Area�. �-,��,. Size of Tank ! ezs-� f `' )
► Mobile Home ►/' Size of Pump Tank �/-$
iness # of Bedrooms�_ Nitrification Line ��' 3� �,�
Max Depth Trenches .�,c,�•�cr .,.{ _
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 (���� ���. G�a,��.�,�
�Comments: ��� -��,,,a,�.�,, � ,�.�rZ �� 1���" � G���.
��� !1�✓_ .. � _.: 2 (/ n . _ n J. _ � /1. _ m / ! _ .� /.
ell
in� Approved
Date
by h10-u.�.., ��-P� Approved by � ��Q ��r�„�.
� LL SYSTEM SP C
Semi-Pub ' Re
Zeplacemen Air `
Reqi
Well
CATIONS
i Slab
Well Lo�
by
Tlils report is based in part on infortnation provided the homeowner or hisMer representative in the application submitted for this permit The
environmental health specialist is not responsible for false or misleading infonnation 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 &om false or misleading
statements provided to him in the application. Neither Petson County nor the environmental health specialist wazrants that the septic tank system will
continue to fundion satisfactorily in the future or that the water supply will remain potable.
ORIGINAL
c:lamipro�permit.sam O1/95 rev.1.0