A23 139-�e�rson County Health Department
:,�v�age System Improvements Permit
Date: �%This ermit Void After 5 Years Permit #�� � 7� �
Owner: —'���Qv� 1oJ�G ��x. SR# �Z
Location/Directions:
Subdivision Name: ��� C L`-h e� ��
Lot Size: �:����'�e � Type of
Water Supply: Private: Public: _
Bedrooms: �✓ Garbage Disposal
Basement Basement Fixture�
INFORMATION CERTIFTED BY�
Environmental Health Specialist:
REPAIIt: REEVALUATIO]
Community:
S
Size of Septic Tank: �����j� gallons! Size f�Pump Tank: �
Nitrif'ication Line:
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remazks:
-�-.,����� /��
Date Well Approved: �
BY
BY �fl�sY•� m-u�w�
Well should be 100 f� from any sewer system
;-�-ia C�
. Environmental Health Specialist
TE OF COMPLETION
Sewage System location, installation, and protection must meet state and local
regulations. Septic 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 hazard. Septic tank and
nitrification line must be inspected and approved by a member of the Person County
Health Department before any portion of the installation is covered and put into use. If
the site plans or intended use change this perntit is subject to revocation.
(G.S. 130 A-335F)
L.ocahon of sewage disposal sewage system sketched on back.
(OVER)
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,�Person �County Health Department
Well Permit .
Date:�+ _ This �ermit Voi� After � Years ; _5 _: `_
Owner. s: a�^ �tc' ,;�r�; � r, �., SR#
Location/Directions: ,
Subdivision Name: i,ri c' --i�•x ; ; ;- •' <` � Lot # _._-
Drilling Contractor: -'
WELL CONSTRUCI'ION
Distance from Nearest Property Line Distance from Source of
Pollution
Totai Depth: FG Yield: GPM Static Water Level FG
Water Bearing Zones: Depth Ft. Ft F� FG
Casing: Depth: From to Ft. Diameter: Inches
TYPE: Steei 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•
Grout: Type: Neat Sand/Cement Concrete
Annular Space Width Inches
Water in Armular Space: Yes No
Method: Pumped Pressure Poured
Depth: From to Ft
Materials Used: No. Bags Portland Cement Weight of 1 bag_lbs.
If mixture (sand, gravel, cuttings) - Ratio: to
ID Plates: Yes No
4 x 4 slab Yes No
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT �
Tf-IIS WELL WAS CONS'TRUCTED IN ACCORDANCE WITH REGULATIONS SET �
FORTH BY THE PERSON CO EALTH DEPARTMENT. �
�
Si natuYe of Conuactor Date
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,� � �
� r'��ir'( �,%� �'�1 :�;� �,t,,T>' _� .�2 =.., � �i�
3� � Sanitarian's Sigrlature` Date Issued
G� Sanitarian's Signature Date Completed
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, wate
s�plies, etc. Note special problems existing on lot. Write in measurements in order that installations may be
located at later date. Note locatinn �f water cnnnl;ec nr, ar�ileent lntc
Special Note: Each application for a Zoning Perait shall be
acco�panied by a plat, drapn to scale. shoRing accurate di=ensions
of the lot to be built upon. accurate diaensions of the building to
be erected. its location on the lot and such other inforsation as
■ay be necessary to provide for the enforcesent of this ordinance.
AUTHORIZATION PERMIT #: rfl-r'74/
" PERSON COUNTY HEALTH DEPARTMENT
� AU�HORIZAT ON FOR ZONING & BUILDING-PERMITS TO E ISSU
�� ( G S. 3 0A - 3 3 8) e,,,,� ��(�„
OwNER: �, PHONE # �g�1- � 7 / Q
_ ADDRES S: - '{� _ n _ �a,ti 11 �"7 �ox�,��� �i . �' _ 0275'] 3
. ,
? LOCAT I ON OF P ROPERTY : t�/ S2 �/ 3�'7 �
LOT SIZE: �'a3 a.C�.e,o TAX MAP #: A�3 ��9
TOWNSHIP: �mm�nn�,,�ti�, �,,�c,� .
S UBD I V I S I ON NAME : ���`f {�, E,� o mr�� LOT #: /
? NUMBER OF BEDROOMS { }
HOUSE {� MODULAR HOME {} MANUFACTURED H01e(E {}
OTHER { } SPECIFY:
DATE : � � - r o - � 3
NEW SEWER SYSTEM {� EXISTING SEWER SYSTEM {}
MUNICIPAL SEWER SYSTEM { } '�
Environmental �alth Specialist
******************«************»*******************,�*****�********.*
Certificate of completion or operation permit issued: (130A-337)
and compliance with local well rules where applicable. (130A-339)
DATE : i'�' � �
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En ironmental Health pecialist
w+r,r,e,t*sr*,t,k**tt,r*,t*trrt,t*w**�*�+r,e�****,r ****,r***w,r*,rw,►*,t�tt**,r,r******,r,r*
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.
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Site Evaluation Application Date:
Fee Collected YES ✓ NO
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��' ��' A�PaPLICATION FOR IMPROVEMENTS PERHIT
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l. Permit requested by:
Address: e�0 D
Home Phone �� :
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owner/pruspective owner:
agent : 'BO�J
_1.Au� L�O. p.�. (�oX 103
Business Phone �r`:
2. Name and address of current owner:
t�t� b
_va�
�5'7 3
kL�y �4 '� Im STnVA�.
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3. Property Description: Lot size: 1• 23 ��-�_�
�6T i 3q
4. Tax map ��: {�.a+3 Townsh.ip: CUUIJIIJ(�1�Pt�n
Subdivision Name: y`c1c4,►aEE.'S LAUOt�I(� Lot ��:
1-�VCO LA►�
S. Directions to property: State Road �� & Road Names, etc.
� o �to o p�.,� P o � � � �. , i N� � 'Ta � i ST .
1.
Ir?.O� -t'O
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 sewage disposal system is intended to serve?
H
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10. Water su 1 rivate? ✓ � � � w
pp y p public. community. spring. �
Other source? (Specify): �
Are there any wells on adjoining property? If so, identify location: �
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11, Type of structure or facility: Proposed: '� Existing: �. �O
Type of dwelling: House: ✓ Mobile Home: Business: �
Type of business: Number of Employees: �
Number of bedrooms: Garbage Disposal? Yes No �(�j
Basement? Yes No If so, number of basement fixtures: \�
12. Clearly stake all corners of the property and the corners of all proposed structures. °
b �
I hereby make application to the Person County Health Department for a site ,�'y
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)
, � .
Signed Owner or Author e� Agent
,
Permit Issued
Permit Denied
Plat Observed
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)?ACTORS - SITE EVALUATION AREA 1 AREA 2 ARF.A 3 AREA 4
S S S S
1. SLOPE (�) PS � S PS
LT
2. SOIL TEXTUEtE (i2-36 in. ) S - S S
(Sandy, loamy, clayey, �� PS PS PS
Note 2:1 clay) �J� U U _
3. SOIL STRIICTITRE (12-36 i.n. ) S S S S
(Clayey soils) P PS , PS
4 • SOZL DEPTH (in. )
5. RESTRICTIVE HORIZONS (in.;
(Im�ervious Strata, rock)
6. SOIL DRAI2IAGE/GROUNDWATER
(bcternal & Internal)
. 7. SOIL PERMEABILITY
(Percolation Rate)
PS
PS
u
PS
S
U
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S
'�S
PS
PS '
U
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S
U
PS
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S
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PS
U
S
PS
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S
PS �
U
S
PS
U
S
$. 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 ECOt�R�I1DATIONS / COt�fErITS :
S�TE CLASSIFICATI021 DIAGRAM (Include: Soil areas, property lines. roads, streams, gullies,
aet areas, fill areas, wells, c�ater bodies, slope patterns, etc.)
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