A23 143Site'Evaluation Application
Date: �,� 02 � �%
F�� Collected YES � NO
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�� � � `�� APPLICATION FOR IMPROVEMENTS PIItMIT
1. Permit requested byc' owner/ rospective owner: �
agent:
Address: ��� �iDrrrE'GEJv-d% f/F. �21�fF
Home Phone ��: o7y'� U 1rc2S • �usiness � o�
2. Name and address of current owner:
_ �"�(� � C�'l .. , __
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3. Property Description: Lot size: / —�j �� C�'�a��-O� �l�O 12c
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4. Tax map ��: �/ a3 ��.3 ownship: V C,/7 n:� .�0�(( �j�1
Subdivision ame: c 1�Q�'�S �Q y,� �r� Lot ��:
5. Directions to property: State �,oad �� & Road Names, etc.
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- 6. Permit requested for: New Installation: !/ Repair:
Additional Renovation re-using present system:
7. Number o£ occupants or people to be served: � '-' li'Q ��iZ�G�U�I
8. Dimensions of Proposed Structure:( Width:
.
Depth:
� r�J
�o m2/ .
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?
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10. Water supply private? public? community? spring? �
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Other source? (Specify):
Are there �any� wells or� adjoinin� property? n If so, identify loc�ation: � -d �
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. . . ...
11, Type of structure or facility: Proposed: ��`�S�{Existing:
Type`of dwelling: House: jf"' Mobile Home: v� Busin
Type of business: �)�/�- Number _ Employees:
Number of bedrooms: 3 Garbage Disposal? Yes Nq �-
Basement? Yes `-- No If so, number of basement fixtures: c�h�i __
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 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.
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Permits are valid for 60 months £rom date of issue. P mis ' is y gra ed to �
enter the property for the evaluation. G.S. 130A-33 . �
_ �`/tita � �''u'GC, ��6E%� � ��� � .��,
igned Owner or Authorize� gen
-�'��".�� �U-� �— ��-�� -� �'u-r` �
Permit `Issued _�
Permit Denied
Plat Observed �
I�ACTORS — SITE EVALUATION
1. SLOPE (X)
2. SGIL TExTURE (i2-36 in.)
(Sands, loamy, clayey,
Note 2:1 clay)
3 SOIL STRUCTURE (12-36 i.n.'
(Clayey soils)
4. SOIL DEPTH (in.)
.5. RESTRICTIVE HORIZONS (in.
(Iu�ervious Strata, rock)
6. SOZL DRAIIIAGE/GROUNDWATER
(bcternal & Internal)
7. SOIL PERMF.ABILITY
(Percolation Rate)
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AREA 2 AREA 3
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$. OTHER (specify) � � pg' p
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9- SITE CLASSIFICATION
(See below) -
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECOI�RgIZUATIONS / COI�IEriTS :
�'l�TE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gulli
aet areas, fill areas. wells, water bodies, sZope patterns, etc.) �
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�,�� �-�rson County Health Department �
S��e System improvements Permit ,,��
,�+ � Date: IL'1 O'��']'hls Permit Void AClcr 5 Years Pcrmit #
N� ; Owner. SR# bL,3ZZ
� �
� Localion/Direclions: _ C�, (� ('��/ Q� (�,L - �C �' <•t.r,,.._ cd,
� �;� Subciivision Namc: G � � 1 �_. Lot # �A
��� Lot Si�c:._.[2`�u��t J,o1.��r�Typc of Dwclling. G:�H, � i r� rci
d�, Watcr Supply: 1'rivalc: ___ � __ Public: - --- - — Ccm�n�unity: ----
� i, t3ulra�ms: � G�ubabc Dis��sal _� �
� Basement � � Bascment Fixtures ' ��� � '
�; INFORMATION ERTIFIED BY F--`" 7 %
, G�G. Y
�. , Environmental Health Specialist: ' �� rcsCntas �
y�N b� � REPAIR: _ — � �1�! �% �T� (�,,�: -
REEVALUATION: _ �
; — — ----------
� Sizc of Scp�c Tank ���� •allons Sizc of Pump Tank: �o�)a •
NitriCcation Line: S i� � j(� '' � '
` Dcp�h of Stone: 12 mches �"
; Max Dcp�h of Trenches:
; Altcmative System: Conv. Pump LPP Pump
' n----�-- ^
------ `-----�----'--l�i�k����'Lo
•1
Date Well APPro��� Well should be 100 f� from any sewer sys�cm
BY Environmental Health Specialist
Date Scwage System Approved:
Bl' Environmental Health Specialist
CERTIFiCATE OF COMPLETION
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� Contraclor. �
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Sewage S��stem location, installation, and protection must meet state and local �
rcgulalions. Septic tank should be pumped out evcry 3 to 5 years anJ shall be maintaineci
� by owner in such manner us not to create a public health ha•r.ard. 5eptic tank and
; nitrifca�ion line must be inspected and upproved by a member of the Person County
; ilealth Depaztment before any poriion of thc installation is covered and put into use. If
: the site plans or intended use change this permit is subject to revocadon.
! (G.S. 130 A-335F)
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I.ocation of sewage disrx�sal sewnge systcro sketched on back. .`
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(OVER) • .
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� � ��r�on County �9e�lth �epa�ment �
� Well ��r�'Y�1� � �
� = �+ i�'his Perrnit Void After 3 Years � � ` — `�
Date:_�� 1�
; Owner._� �r f�.� y'T �'��C%%��-��;�a.-.+/ SR# ��7 �� I
= � I.ocauon/Direcdons•
. _. � .
Subdivision Name: ,
Drilling Contractor.
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WELL CONSTRUCI'[ON ':d
- Distance from Nearest Praperty Line Distance from Source of �
Pollution � �
Total Depth: � Yieid: GPM Staac Water I.evel F�
Water Bearing Zones: Depjl� F F� F� FG
Casing: Depth: From S� to _ Ft Diameter: Inches
TYP& Steel • Galvanized Steel ✓
If Steel, does owner approve� No
WeighC Thiclrness: Height Above Grtound: Inches
Drive Shce: Yes No
� Were Problems Encountered in Setting the Casing? Yes No
If "yes". give reason: �
Groiu: Type: Neat d/Cement Concnete
Armular Space Width Inches
Water in Armular Space: Yes No ,/
Method: Ptanped Pres Poured
n�: � �� � � FL
Materials Used: No. Bags Portland Cement Weight of 1 bag
lbs. .
If mixwre (sand, gra�k �aings) - Ratio: to
ID Plates: Yes No �
4 x 4 slab Yes s� No q
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
TI�S WELL WAS CONSTRUC�'ED CCORDANCE WITH ULATIONS SET
1�ORTH BY 3'HE PERSON COUNTY�i.'I�jDEPl�['MENT.� _ � ��
Sketch well locarion on reverse side.
Date
Sanitarians Signature Date Completed
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7���.a-��� ����.]L IE-7L��.7L�II�
Applican.
Location:
T��x M��� � � P���rce�l �
S�uhtilivis�ion ,r�� „„ i
Ph��se�Section Lot #
�i�_viTF
Improvement Permit
Permit Valid for ✓Fi e Years _ No Ezpiration
Type of Facility:
# of Occupants # of Bedrooms Proje
Proposed Wastew�ter System: (�,i/s/�,�/,�pn/„d,�
Proposed Repair: �i
Permit Conditions:
Owner or Lega1 Representative
Authorized State Agent: �
0
New �Addition Water Supply �s�_
ed Daily Flow �D g.p.d.
W�n� � �,� n
0
Type: �b
Type: ��_
Date: % / 0
Date: �/��.
The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsi'bility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rules for 5ewage Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warrants that the septic tank system will continue to function satisfactorilx in the future or that the water supply will remain
patable.
Authorization to Const�uct Wastewater System (Required for Building Permit)
* See site plan and additional attachments (�.
Proposed Wastewater System: ���/�/��n/� �'`'�pUN,� Type �Tf��o Wastew ter Flow _���.p.d.
New �/ Repair Expansion _ �-� Soil LTAR: � g.p.d./ ft 2
Type of Faciliry: _,�p,�c,r Basement ✓Yes _ No
Wastewater System Requirements
Tank Size; 5eptic Tank: �a�/'" srPunip Tank�'�' gal Grease Trap: gal
Drainfield: Total Area: ?�D D sq ft Total Length _�� ft Maximum Trench Depth lZ -/ in
Trench Width 3 ft Minimum Soil Cover: � in Minimum Trench Sepazation: 9 ft
IDistribution:
� Specifications:
Distribution Box Serial Distribution �i _ Pressure Manifold
Authorized State Agent: Date: _ e��-`�-
Pennit Expiration Date: p q
The type of system permitted is � Conventional Innovative Alternative. I accept the specifications of
the permit.
Owner/Legal Representative: Date: � / O
PCHD7/30/2002
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SITE SKETCH
N�me � D �' ��,�.��/✓
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Subdivisi �ri.,,.. / G� ��
. .Elittho�iz d te Agent
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Tax. Map #=��. Parcel # 14��
Section/Lot# �
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Date �
� Sysie»: cos�apo�e�zts i�ept�esent appro.ximate contoura only. The contractor nzust, flag tlze system prior to beginning tlie installation to insure tjiat
�i�•bpe�•grade is �rtaintained �
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Tax Map: Pazce] #: l Date:
Line Tap Tap (Sch) Tap �'low Line Length Tlodv / foot
# Dia�eter in) ( m) ., (ft)
1 �� p � � �6� ' o o-T!
2 % U . I /DO � �. �
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4 �/y O o � � o
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6 -
7 • .
8 M
9
10 -
� � ft of line x 65 gal. per 100 ft= : 100 =7-�� gal
75% x?-.�Q gal =/�� gal per dose 24� gal per minute (gpm) = Flo�v ISate
Friction Hea�1
L,oss: �/-'7`b—ft per 100 ft of supply line x/DDD ft of supply. line =100 =�ft
/7• �S ft x 1.2 =?�%• 3loft of friction head
/ ��-t/���1/
,�'��D %� Manifold Size: ? " Force Main Size: Z" PVC
�,,y���p �otal Dynamic �ead � ft of Elevation head +� ft of Pressure head +��- ft of
Friction Head = TDH
��9�� Pump Requirement: �_ GPM @_�� ft of Head
�D'� '�� Drawdown: /��,� �al per dose = 21 gal per inch =� inch drawdown per dose
,���.Q� �,�� .
��,u p . Geen�rat Design �ormation . . .
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Size / # Taps
No. Taps off one
�v %a for taaAin� �
4�+ � 21
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. . . - - . - Fiozv er Ta
�lyE Masericrl r'To�� G��1
l.c �� Sched 80 �•5
�. ,� Sc;ted 40 7.1
3, " Sched 80 10,.1
',�{'• Selted 40 12.J
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IC �rn�a �- � �a �c�n. � �rn �.a�:ll IE-33L � .�n.11 �Il-n.
Applicant: ��P,�- !LI c��j�P,,rS�,•,
Location: _ _ _
/
Tax Map � � P��rcel #
Su.bcfivision %'-
I �
Fh�se Section Lot #
# of B�drooms �
Operation Perm it
System Type (In Accordance With Table Va):
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORI TION.
vve/ 9'--�=�
uthorized State Agent Date
Installed By:��� �� Date: ZS�i2`� �
L� `� P v'�•
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PCHD, rev. 07/29/04
❑
5��� ���� d�����i��� ������� ��� gd�_��
Tax Map #,� Z3 Parc�! #� System Type (Table Va) .
OwnedAQpiicarrt �c i'!� nan Subdivision _/VirG,he,e`Sl�..,�C,�,�.,�
AddresslLocation � SeclPt�ase Lot # �
.
State ID/da#e
Capaa
Tee and Flter
Baffle t
� Sealant
� Riser ifi ap iicable
Tank Outlet: Seai
Perrnsner�t Marker
� - - Pu�p Tank
/Seaiarrt
� Riser . � !l'� " -
Water Tigtrt �
.. Pump"
�edc Valve/Gate Valve . ; �
. . ip on o e . .
•' �OatS%�WI�Ct'iPS': . .. . .. .
. Alarm (visable and aud[ble)
Approved Pump Mode! ��,.p, ( �
Btodc Under Pump
Pump Removai RopelChain
Distribution System
Seriai Distribution '
ressure an'
Low Pressure Pipe �
Aapr. Piae Mate�a! and Grade
VVidth .� ft.
DePth IZ -y_ iri-
Len9th y Y � oa ft.
Trench Grade
Trenct� S acin
Rodc De th and Quai'
� DamslSte owns etc. �
Pressure Laterals
Hole Spaang
oe ��� � . �
Pipe Sieeve . � . - .
� Tum-upsfProte�iors �
�Requir�d Se�acics
From Wells •. � �
From Property lines �
__ _ Struc�ur'eslBasemerrhs.:: �
es � rainage � ays �
$�Ii'�'df�.'`�(2tBl5 ' ' ' ' '
� Public Water SuppGes
Vertical Cuts �>2 ft. .
Wate�- Llnes
Vehide Trafiic
EasemerrtslRight of �t1h
� Other.
Easemet�ts Reaorded .
pe r m
Tri-Partate Aqreemerrt
I�
Comments�
� . pct�d rev. 3113/01