A23 140• - z
Person County Health Department �
' Sewage System Improvements Permit
Date:_���� ' ermit oid After 5 Years Permit #
Owner: SR# T,�?'�
Location/Directions:
Subdivision Name: Lot # Z
Lot Size: �%CZr C t-�– Type of Dwelling:
Water Supply: Private: —y� Public: Community:
Bedrooms: _� Garbage Disposal
Basement Basement Fix
INFORMATION CER'I'IFIED BY
Environmental Health Specialist: I a e �ad�e
1�yw�
REPAIR: REEV ATION: W�'� "�r� �_-�:_.
-------f-�+--,++�*------------f�'rrr -�
Size of Septic Tank�-1L��'�`�
Nitrif'ication Line:
Depth of Stone: 12 mchess�
Max Depth of Trenches:
Altemative System: Conv. Pump
Remarks:
gallons S' of Pump Tank:
/ Y � � ,� ,� �,► , � �
LPP Pump �'
�
Date Well Approved: Well should be 100 ft from any sewer system
BY Environmental Health Specialist
Date Sewage System Approved:
BY Environmental Health Specialist
CERTIFTCATE OF COMPLETION
Contractor.
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 pians or intended use change this pemut is subject to revocation
(G.S.130 A-335F)
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
Site Evaluation Application Date:
Fee Collected YES � NO
. . �oy �i q
$��' APPLICA � N FOR IMPROVEMENTS PERHIT
� c1� 3��,
1. Permit requested by:
Address:
�
owner/�prospective owner: � RkT�
agent: �Ak�_X
Home Phone af: tsusiness rnone �f:
2. Name and address of current owner: S A m O Attl.�'
P. t� _(%� r„c . � 0 3'� , lZ- o�c.. bo R.o ►J L a-1 S-l3
3. Property Description: Lot size: .`l O A C
� � 4
z
> ► m�So1.� °'
s
� �S �
�G - 0�1 I
St r�n S-i'o V ALL.
4. Tax map ��: Township: CU N IJ �►J � N��
Subdivision Name: Mc �NEL'S 1_Af.�[�i til l�� Lot ��:
S. Directions to property: State Road �� & Road Names, etc.
oFF oa� �Doi�-t� �tt_���:
�
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?
10. Water supply private? ✓ public? community? spring?
Other source? (Specify):
Are there any wells on adjoining property? ,/ If so, identify location:
H
O
11, 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: �
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 repres�nt 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)
: `��� d2U,��� . _ � �
Signed Owner or Autho zeci Agent
H
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Permit Issued Zi
Permit Denied
Plat Observed ti�
+ . . �.,—
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l�ACTORS — SITE EVALUATION AREA 1 AREA 2 AREA 3 AREA 4
S
1. SLOPE (X) PS PS P PS
U �
2. SOIL TEXTURE (12-36 in. ) (� /�� ,�'� � g f�"
(Sandy, loamy, c1aYeY, P �O �17°� PS �/ �f 1 PS � D r` � P 3� c>
Note 2:1 clay) ��s � �{v
3.. SOIL STRUCTtTRE (12-36 in. ) S S S �
(Clayey soi.ls) ps � � ps
U
4. SOIL DEPTH (in.)
5. RESTRICTIVE HORIZONS (in.
�Im{�ervious Strata, rock)
6. SOIL DRAINAGE/GROUNDWATER
(bcternal & Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
U
U
S
S
S
,�
S
�
U
S
PS
PS
U
S
PS
PS
PS �
U
�
U
S
�
U
�
U
�S �
U
PS
S
$. OTHER (specify) PS PS PS PS t
U U U U
9. SITE CLASSIFICATION
(See below) � S S �
SOIL SERIES
S- Suitable PS - Provisionally Suitable � U- Unsuitable
R ECOt�4fENDATIONS / COr4tENTS :
�ETE CLASSIFZCATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies,
aet areas, fill areas, wells, �aater bodies, slope patterns, etc.)
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A001013
• PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
' T� Map # ���, Parcel # % ` . �
Zoning _ Toavnsr.ig C� '� �
Owner/Contractor� � /�,�� ��' S��Y» S� � _ te ��,y �3 ✓�>�
Location/Address <flCr i 333 � s�� 1322 � o� 'l��%�� s�_ 1fPA.v .�'r.;,'�t U-�
Subdivision Name
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altere o nte e us changed.
Well and Septic Layout by < �
Comments:
Date��[� Installed
Comments:
Date
Installed by
Approved
This report is based in part on infonnation provided the homeowner or his/her representative in the application su8c�tted for this permit The
environmental health specialist is not responsible for false or misleading infocmation contained in the application. The environmental health specialist
is also not responsible for concealed conditions on the propeity or for staiements in this report that may have resulted from false or misleading
statements provided to him in the application Neither Person County nor the environmecrtal health specialist wazrants that the septic tan ; system will
coirtinue to function satisfadorily in the future or that the water supply will remain potable.� a�amipro�pennitsam Ol/95 rev.1.0
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERNIIT
Tax Map # �� � Pazcel # �
Zoning Township C
Owner/Contractor � /1, �G,,, �- S,�m p Sm � te � f�'-�3 ✓��� � /� ��-,
Location/Address 322 0� ��;�� s f�'PP �-�
nn k(�n�;,a-P Dr� ve �Io lr F Or�r�e t-ea� A� r�"�t' �/ot.z- S.R.# / 3�j
Subdivision Name
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area ,'7(] ��-c Size of Tank
SFD Mobile Home Size of Pump Tank-�//��/% .
Business # of Bedrooms_�_ Nitrification Line� � � � %'�
Max Depth Trenches �,� �' - 3c7 " ���
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations. ��
Pernuts may be voided if site is altere o nte e us changed. �' `'' f S�='� �
W e l l an d S e p t i c L a y o u t b y < y�y� c� '�°'"' �� X.�
Comments:
Date Installed by Approved by,
P o WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab
Public Replacement Air Vent
Site Approved Required Well Loo
Well Head Approved Well Tag
Grouting Approved
Comments:
Date Installed by Approved by
'Iliis report is baseci in paR on information provided the homeowner or his/ha representative in the application submitted for ihis pemiit The
em�ironmental health specialist is not responsible for false or misleading infom►ation contained in the applicatioa The environmental health specialist
is also not responsible foc concealed rnnditions 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 warrants that the septic tank systcm will
- continue to fundion satisfadorily in the future or that the water supply will remain potable.• c:�amipro�peinutsam Ol/95 rev.1.0
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Owner• � �-
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I,ocation/Uirections: —�j-,�-,� �o � �-f- _ ----- � � : '
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�ub��vision N���ic: _._�_ . —__-__- Lot # ,
. . __ _ ___ _
Drlll�ng Contractor:�-_,�_,L���_ ,�r, )j,�n �
W1 I.E , CC)Nti I RIICTIQN . ��
Distance from Nearest l�rope��ty JLi�ic._ /���u s__ Dist;incc t'rom Source of ' �
;,,
Pollution � - ��
ws • .
Tocal D�.ch: � o Fc. Yi�l�i� �_-- -- �' .�
��� .�- GI M S tatic Water Level F�, ' ;:
Water Bearing Lones: Depth �� --1't• �"t- Ft. . ��
Casin — .�t. `: ,
g: Depth: From___�___--�o^ �,(� __ Ft. lliarnc[cr: � ,
TYPE: S teel -- . — � Inches � ;;�
� Galv.lnlzccl Stec;] �-- . . � {
Z,F Steel, does owncr approvu: ycs No � �}'`
4.�
W�.ri ht. ' � .t'r.
$ -- % �____ I'hickncss: �� ,Height Abov.e Ground: �J ; =�n�hes x ��
Drive Shoe: Yes ��� ; . �*,;,�
Were I'roblems Encotiiitercct in Scttiilb the Casin�? Xes �� � No i�`
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ze ��y�s�� � — .h
give rcason: : ,
Grou[: T Neat � "��s �
YP�� S.�,�cl/Cc�ilen� Coricrete ' ' ; r�:� `,�.c
Aruiular. Spacc Wi�lt}i , t,:,,,
—� ------ Inches . ,
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Wa[cr in Annular ' , . � ;.
S �icc: � �
d: �„ Yc.;_ __._ No � Yw:
Mc[ho Purti�x:c�-- ----- I'rc�,surc: I ourccl � � . . . . . ' ,'.
Dc ch: From ------ __ ��
P. ---_--�__ �u _�_� I��. .. .
Materials � � � � � �'
Useci: No. �a�s .['orcl�uid Ccmcnt Wei ,,
If mixtuie (sand, gravcl, cultiri�;t) - IZatio: �— �t of.l�ba�lbs;; ,«{�
� to �< 5�:
�ID Plates: Xes � No_ _. _. . � � :.' • ��,�'
4 x 4 slab Yes -� No
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Z HEREBY CERTIFY THf1T TI-IE A,BO r L 1NFORMATION IS C t,�
� � ' ORRECT AN] - . .. p_'�;�
. T�S WELL WAS CONS 1,RUCTED 1N ACCORllANCE WITH REGULAT'IO
FORT�I �Y�THE PERSON COUNTl' IlI;A1;I'E-i DCPARTMENT. .
_ — ���-� _1��
Sibnaturc c�C Contractor
i � � � r :.��
Date ' ''s:`�