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Person Co�nty Health Department �
Sev�age �ystem Improve,ments Permit
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Date:��,t-�'rhis Permit Void After 5 Years Permit # �� � f�
Owner: _ ,. ,:� ,__ -� ' s-: SR# ��L
Location/Directions: ( �-� �a�y �� �-� ��� ..
Subdivision Name: �1 �� � ��' "1 ��E' Lot # �' � `�
Lot Size• -� � � � � • - Type of Dwelling:
Water Supply: Private: ��` Public: Community:
Bedrooms: 3 Garbage Disposal
� Basement Basement Fi j
INFORMATION CERTIFIED BY - ���---�'�
Environmental Healih Specialist: f 2. , ,� o�entative
REpAIR; ' REEVALUA'TIO : -- —
Size of Septic Tank: _��� allon� Size of Pump Tank:
Nitrification Line: �����. �
Depth of Stone: 12 inches
Max Depth of Trenches: —
Altemative System: Conv. Pump LPP Pump
Remarks: i ,� ._-! �-1 i7 ; j� ICr ��._�:•7-
Date Well Approved: Well should be 100 ft. from any sewer system
gy Environipenta Health{Specialist
Date Sew� Sy m� p roved: t� -- �
gy Environmental Health Specialist
°, '/T `" TIFICATE O COMPLETTON �:
o Contractor.
� , - �
o--------------------------- �,
� Sewage System location, installadon, and protection must meet state and local �
A � reguladons. Sepdc tank should be pumped out every 3 to 5 years and shall be maintained
� by owner in such manner as not to create a public health hazazd. Septic tank and �
� nitrification line must be inspected and approved by a member of the Person County
x' Health Depaztment before any portion of the installation is covered and put into use. If '�'
y the site plans or intended use change this permit is subject to revocation. � j
b
�: (G.S.130 A-335F)
�
y Location of sewage disposal sewage system sketched on back.
8
� (OVER)
M
Site Evaluation •Application
Fee Collected YES ✓ NO
f' � ���/
Date: �� -� �y-� �3
APPLICATION FOR IMPROVIIfENTS PIItMIT
1. Permit requested by: owner/prospective owner:
agent:
Address:
Home Phone ��:
2. Name and address of current owner:
nusiness rnone �f:
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3. Property Description: Lot size: • 9�
4. Tax map ��: Township•
Subdivision Name: (� �� ��Q.� �� Lot 4�: �
5. Directions to property: State Road �� & Road Names, etc.
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.
10.
11,
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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?
Water supply private? ✓ public? community? spring?
Other source? (Specify):
Are there any wells on adjoining property? If so, identify location:
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:
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12. Clearly stake all corners of the property and the corners of all proposed structures.l
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)
� ned Own o A thorized Agent
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Permit Issued t�
Permit De ie
Plat Obse ve
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rACTORS - SITE EVALUATION AREA 1 ARFA 2 ARF.A,3 AREA 4
S S S S
1. SLO�'E (X) PS PS P5 PS
� U
2 . SOIL TEXTURE (I2--36 in. ) .� �• S ✓ "
iSandp, Iaamy, clayey, l�'� 't�.�/ S yC �P�' ��/,�I►`.� 3° �dz�. S�� �t�� ps ilivf uS
Note 2:1 cla ) U � �_� U I-���co So � U 3!� " �J �•
3.. SOIL STRUCTITRE (12-36 ia. ) � � . S . g """
(Cl.ayey soils) pS (� 5 PS
U U `i�— U
_ S S g S _�
4. SOIL DEPTS (in.) S PS 5 PS
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S. RESTRICTiVE HORIZONS (in.) S S S S
(Im�ervious Strata, roek) P p�
U U
6. SOIL DRAINAGE/GROUNDWATER S S - S '�
(External & InCernai) 5 PS PS '
U
7. SOIL PERMEASILITY • S S
RME
(Percolation Rate) PS � S PS
U U - � U
� S S S S
$. OTHER �specify) p5 P5 �'5 PS r
U U U U
9• (See bC 1tiw)FICATION � � � � ��, , .
SOIL SERIES
S- Suitable PS - Provisionall Suitable U- Unsuitisble
RECOt�fE21DATI0NS COI�iII1TS:
�
�L�TE CLASSIFICATZON DIAGRAM (Include: Soi1 areas, property lines, raads, streams, gullies,
Wet areas, fill ar�as, �aells, water bodies, s1op� patterns, �Cc.)
�
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Special Note: Each application for a Zoning Perait shall be
accoapanied by a plat, dravn to scale. shoAing accurate di=ensions
of the lot to be built upon. accurate disensions of the building to
be erected. its location on the lot and such other inforsation as
aay be necessary to provide for the enforcesent of this ordinance.
AUTHORIZATION PERMIT #s �� �
PERSON COUNTY HEALTH DEPARTMENT
AUTHORIZATION FOR ZONING & BUILDING PERMITS TO BE ISSUED
�, <G.S. 130A - 338) g,o�1 g�6_ �13�
OWNER: � �"y' fi"^ �o�� � e� PHONE #: J
eX e�r'�K � JJ.��
ADDRES S: i 9 rr -`�� ��► A-re� D r� 1� �,r� v� 11 e� �/�- a-4 S��
LOCAT I ON OF PROPERTY : c��� S�� l�2Z
LOT S I ZE: D, � 3��-+/e- TAX MAP #: �=�-„1-�-�-�
TOWNSHIP:
SUBD I V I S I ON NAME : �\ �o �`�-�C S7� LOT #: ��
NUMBER OF BEDROOMS '{3 )
HOUSE {v } MODULAR HOME {? MANUFACTURED HOME {}
OTHER ( } SPECIFY:
DATE : �L��
NEW SEWER SYSTEM {� EXISTING SEWER SYSTEM {}
MUNICIPAL SEWER SYSTEM { } ��
� Environmental Health Specialist
**,r*****,�******'**,r**�r*****x****�r*******�*********,r*********_********
Certificate of completion or operation permit issued: -(130A-337?
and compliance with local well rules where applicable. (130A-339)
DATE : I ""� � 1 - ^ ^ _
Environ�ental Health_Speci�list
,►**********************************«*******,�****************«*****,�
This is to certify that the above named addition to my property
will not cause an increase in sewage flow or interfere with the
operation of my sewer system. I certify that my sewage disposal
system is functioning properly.
- Owner or Agent
YOU MUST OBTAIN PERMITS REQUIRED BY THE PERSON COUNTY ZONING AND
BUILDING CODES BEFORE ANY CONSTRUCTION ACTIVITY IS STARTED.
1
PERSON COUNTY HEALTH DEPARTMENT
WELI� _�EWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
Tax Map # �� ,�V��,',,_J Parcel # 1 � �
Zoning Township �, u r� �` 1��,,.��,
Owner/Contractor --- _ ate 5 -,�'' `1 �
Location/Address
S.R.#
Subdivision Name G1.� b: ,c- � Lot# � S
A 1314
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area � 3 C� Size of Tank �U �
SFD ��_ Mobile Home Size of Pump Tank
Business # of Bedrooms � Nitrification Line 9,1� -;
. Max Depth Trenches
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� ����� �o o,v�-l�.
Comments:
Date
Installed by.
Approved by
WELL SYSTEM SPECIFICATIONS
Individual_�Semi-Public Required Slab C�
Public Replacement Air Vent
Site Approved Required Well Lo� C�
Well Head Approved 1— — Well Tag GG��Ci l-20'��
Grouting Approved �
Comments:
�
�
�
Date � Installed b��""'�`n� w�,, A�iproved by�`= `��r �
This report is based in part on information pro the omeowner or his/her representative in the application subrru ed 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 repoR that may have resulted from false or misleading
statements provided to him in the application. Neither Person County nor the environmental health specialist wazrants that the septic tanlc system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�peimit.sam O 1/95 rev.1.0
ORIGINAL
Jan 22 99 09:25a Paul Goodman Jr. 804-792-7732 p•Z
01/21/1999 16:Be 5971799
� � .
Date: �'�� �
Qwner: �= '
Loca[ion/Duections: —
PLANNI��G F�61D ZONIhJG
PERSON COUN"iY Er�VTRON[1EyTr;� HEA�,TH
WELL LOG
PAuE 02
SR1#
1_��r�� �}^ �/ �� l %'�'
Subdivision Name: .. _'� � , `� _ Lo[#
�riiling Cbn�a�to�: ^� �:�� `�3`�� - -
WELi� CONSTRUCT�JN
Distance from Nearest Propetty Line �0 1�istance from Source of
Pollution � 16
Total Depth: •�� �t. Yield:,_,,,_.�_ GPM Scatic Water Leve1�5 Ft.
Water Bearing Zones: Depth o Ft, So Ft_ �`�° Ft.. �6�-�t.
Casing: Depth: From��_to a�- Ft. I�iameter: Lk1 Inches
TXPE: Steel � � _Galvanized Ste�:l
If Steel, do� owner apgr�ve: Yes ���
Weighi:�,_,,.Thickness: Height Above Ground: �a- Inches
I?tive Shoe: Yes No '�
Were Problems Encounte�ed in Setting thG C'a.sin8? Yes No �
�f "yes" give reason:
c�c SandJCernene_ a�� ,la Concre�e
Gront: Type: Neat rnth� � —
Annulaz Space Width � � h Inc}lc`
Water i�n Annulat Spa�e: Yes N�__``'
Method: Pumped . .. _ Pressure - - Poured �.-� �
Depth: From �d to �a Ft.
Materials Used: No. Bags Portland Cemeni_ � W eight vf .1 bag e1�� lbs.
If mixtt:re (sand, gravel; eutvngs) - Ratio;___�,.� �o�
1D Plates: Yes � No
4 x 4 slab Xes ✓ No .
Z HERE$Y CERTIFY THATTHE ABOVE I�fFORt�a �TION IS CORR�CT AND THAT
TH7S WELL WAS CONSTRUCTED IN ACCORUANCE WITH REGULATIONS SET
FQRTH BY TH� PERSON COWTY HEALTH zaI;PARTMEN�'.
�.�,�� � ' ...----
Signaturc of Contiactor D���=