A23 147- -. �erson County Health Department �
Sewage System Improvements Permit
Date: "�3 This Permit Void After 5 Years Permit # �l
Owner: SR# j� 3 Q
Location/Directions: �✓ ', L ��� "� 7 2 7
_
� ., �-, ,_.t, f �
Subdivision Name: . Lot # `
Lot Size: -� P S Type of Dwelling:
Water Supply: Private: �_ Public: Community:
Bedrooms: �- Garbage Disposal �
Basement Basement F'
INFORMATION CERTIFIED B
Environmental Health Specialist. � o e` °` es r�u�e
REPAIIt: REEVALUATIO :
Size of Septic Tank: � gallons S'�ze of Pump Tank:
Nitrification Line: �'� 3
Depth of Swne: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks:
-------------------------
Date Well Approved: �-�� Well should be 100 f� from any sewer system
By Environmental Health Specialist
Date S g te Approv 2-�/ - 9�f
gy Environmental Health Specialist
p TINiC OF OMPLETION ,.�
Contractor. � �e
------------------------- �
�
Sewage System location, installation, and protection must meet staie 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 Counry �
Health Departrnent befoze any portion of the installation is covered and put into use. If
the site plans or intended use change this petnut is subject to revocation. �' � Z
(G.S.134 A-335F) � rn -A
� �1_�
� ��
Locadon of sewage disposal sewage system sketched on back. �
���
(OVER) t 2
� �
m
,NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
�,� c'�o �,� �,�
� - �'`Person County Heaith Department �
Well Permit �
Date: -'� This Permit Void After 3 Years
Owner: 1 h 5 SR# �.%�
I.ocation/Directio . - - - . . _ .. �� ��? �
Subdivision Name: ' " ' � '" Lo �"
Drilling Contractor. � __ _
WELL CONSTRUCi'ION
Distance from Nearest Property Line Distance from Source of
Polludon�
Total Depth:l FG Yield: �_GPM Static Water Level FG
Watet Bearin Zones: D t Ft. Ft. Ft.
Casing: Depth: From � to FG Diamet�r: �� Inches
TYPE: Steel Galvanized Steel ��
If Steel, does owner apptove: No
Weight: Thiclrness: Height Above Grotmd: Inches
Drive Shce: Ycs No
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason: I
Grou� Type: Neat San ement Concrete
Annular Space Width Inches
Water in Armular Space: Yes No �]
Method: Pumped Pres Poured � k
Depth From � to FG
Materials Useri: No. Bags Pordand Cement Weight of 1 bag ,�
lbs. �
If mixture (sand. gravel cuttings) - Ratio: to
ID Plates: Yes J No
4 z 4 slab Yes �— No �
I HEREBY CER'I�Y THAT THE ABOVE WFORMATION IS CORRECT
'THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTTH REGULA
FORTH BY THE PERSON COUNTY HEKbTHrDEPAI;,'T,IvIENT. i{
Sanitarian's
Sanitarians Signattue
Sketch well location on nverse side.
W
�-
�
�
�
�
AND 7'Fi � �
TIONS S�•
. �
Date Issued
�3
ie �
2�l% �
Date Completed
Amount paid. � � l�
�
Rec'eipt�:� ff�'�g�
�
H
O
�
�
W
U
�
a
Improvements Permic(Fstablished/Recorded Lot)
ImpFovements Permit (Unrecorded Lot)
Permit (Mobile Home Replace�
5- a--�7 �
Date
ion of Existing System (Loan Closing)
_ Repair/Replace existing Septic System
Permit for New Well
— ----� -
Improvements Permi[ (Addition) ' Replace Existing Well
1. Permit requested by: . �
owner/prospective ow er/a ent: .
Address: .3� R � �J�/'
�i �LhA�4. �% C.r ��'7T �
z
ome Phone #: �' �/a � 5� � � S ��
usiness Phone #: 59.�I- ��%%
Name and address of current owner:
Description: Lot size:
Tax Map#: /� � 3
Parcel#: �``�- �
Township: c vnRa'„ ��-�
Directions to property: �tate Road #& Road
ames,gtc. . , _ __ _
7. Dimensions or Proposed_Structure: . , , ,
Width: ag� � � . ' :
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility .
that this sewage disposai system is intended to serve?
9. Water supply t}pe:
private �j . public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No [�.
If so, identify location:
10. Type of structure/facility: Proposed: I�Existing: Q
Type of dwelling: ,-
House: ❑ Mobile Home: Ct�'$usiness: ❑
Type of business:
Number of Employees: .
Number of bedrooms: � �
Garbage Disposal? Yes ❑ No �!
Basement? Yes ❑ Nofl If so, # of basement fixtures:
6 Number of occupants or people to be served• �_� �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURF,S•
I hereby make application to the PerS0I1 COunty �Iealth Department for a site evaalualication ahe t�rue ite
sewage disposal system for the above described property. I agree that the contents of th�s pp
and represent the maximum facilities to be placed on the property. I understand if the site is altered or the
intended use changes, the permit shall become invalid. I understand that before an Improvements Pecmit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to-the Health Dept. wi�iin 60 DAYS after the date of the evaluation of
the site by the Health Dept., this appl�cation shall become vocd and all fees paid forfeited.
Signc� Owner or Authorized Agent
permi� Issuec� ❑ Signature Date
permit Denied ❑
Plat Observed ❑ �.
�
g�s,i'.f'4'ax��YL....c£.: Ft�+CfO_RS$.IiEEVALUATION`"'rE�t ar� S '� ���s��xs.( z : ���[ � nja, �.,Y{..AREh3s. y� f s,r<r�$z ,pc. 4s x :z
l..r. Tn���.y�"1Qn d .!�;; � ji, �.tti.:... t:.:-., t..NF.(< M�✓� . F1. >�.b'''i'.
1. SLAPE (%) S S S S
PS PS PS PS
U U U U
2 SOA.TFXTlJRE(12-361N.) S S S S
(SANDY, LOAMY. MYEY. NOTE 2:1 Clal� PS PS PS PS
U U V U '
3. SOi[.S7RUCiURE(12•�61N.1 S S S S
(MYEY SOR.S) PS PS PS PS
U U U U,
3. SOILDEYTH(IN.) S S 5 S
PS ' PS PS PS
U U U U
3. RES'[RIC7IVE NOA120NS ((N.) S S S � S�
(R.tPERVIOLS STRATA, ROCK) PS PS PS PS
u u u u
6. SOILDRAINAGFIGROUNDWATER S , S S S
(EXTFRNALQ WTFRNAL) PS PS PS PS
U U U U
7. SOII.P£RMEASIISTY S S S S
(PEACOIAA7ION RATE� PS PS PS PS
- U U U U
E. AVAILABLE SpACE S S S S.
PS PS PS PS
U U U U
9. SITE CUSSIF7GTION(SEE BELO�
SOILSERfES '
S-SUITADLE PSPROYLSIONALLYSU[TAIILE UtlNSUITAELE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFTCATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.� C:MMIPRO'�DOCSAPPSEC.5�1 FWANCEPC
�
�
�
�
w
�
a
B 1654
PERSON COUNTY HEALTH DEPARTMENT � '
WELL AND SEWAGE SITE, LOCATION Ilv�ROVEMENT PERNIIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shatt be issued untit Authorization for waste water system construction
has been issued.
Tax Map #_� � �
Location/Address
Subdivision Name
Parcel # � �J�-�%
Township G U n n i' �!, ,,,,
„ve� Dae ��-�i7
- - - �- l313
Lot#
S.R.# I 3 Z 3
SEWAGE SYSTEM SPECIFICATIOIl1S
epair Lot Area P Size of Tank -��t,'� '
SFD Mobile Home ✓ Size of Pump Tank N�`� ��
Business # of Bedrooms L Ntrification Line �—�X�'� ".;
Max Depth Trenches
Permits may be voided if site is altered or i
Well and Septic Layout by
Comments:
�dVetl Permit Paid ❑, WELL SYSTEM SPECIFI�ATIONS
ell Head
Date
i-Public
Installed by,
�uired Slab
Air Vent
Requireci 11 Log _
Well T
' _Approved by,
This report is based in part on inforfifation provided the homeowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The environmental health speciaiist 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 applic�tion. Neit�er Person County nor the environmental health
specialist warrants that the septic .tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
�
AUTHORLZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: � �—q �I ^=�'ROVEMENT PERNIIT #: I3%�o5�
TAX MAP #: PARCEL #: I �
OWNER/OWNER'S REPRESENTATIVE: G, cv
LOCATION/ADDRESS:
SUBDIVISION NAME:
S�L# 1.3.23
LOT #:
. SECTION OR BLOCK:
. AUTHORIZATION FOR CONSTRUCTION ISSUED BY:
AUTHORIZATION CONDITIONS
1. The Wastewater system constnzction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Pernut # / 3" . The
construction and installation must also meet all applicable rules and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any alterations in site or soil conditions (including structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authorization and associated pernuts.
4. Conditions:
Permit written to allow the Ye
�n,� �� 11.o�.e c�� � � �f G�P �1� ��, � �,d 4 ��,� � �,� s�;(Q 1�,��
with no chanQe or addition to the existin�,se�tic system
Person Requesting:
CONTROL
CORNER
IF
3
n
0
m
01
.I
.o
�
(S
0
�,
��
� ';
� N ^
� N �
�
1. 00
ACRE
N63o
�_ 4l-„
�
,1
,�
',' ( _ _ _ R.B. DAWES, JR.
`''t� D.6.173. P. 632
� =, i
„�
:t
S86•16'���w
686. '
f � �,
_ _'. . � � /NS
! ' ;
/q��
�
� .�� ,�o�
/ '' a�Q �q'L \
./.•`r \
- y'� N$/
'\v,1 b1� •
�� ���'i
MP � IS
24.23'
m
0
1 �
Z
w
�
� w
� v�
Q
w
�
� w
w �
U cv .
U ;� �
Q N .�
O p �
O o � �
� Z
i
1 �
z
ti
�
�
ti
X
W
,
,
N86°16'21"E
25.37' ��
I MP \ IF
_- �
N84•46'03"E N10°04'26"E
�— 243.70' 1 W MP'I 25.74'
�o
� N p� �
�--- - - . .. - � � � I
I ° �
. . ' � I
� � "'F . Z
, ,4, N $
/ �
1 � �
� �
; ' � ��^ti ,
� � CHES
SEMENT_-r- � � HOLBR
p�p NS '' D.8.146,
� � ;'� � � D.B.146,
e,
� :'' `' �> I
v �
0 0;
. �� �
✓ �, 25.��� � 2
IS '` MP' I
S83°59'28"� S83°59':
98.73. IF 20�.2;
� , TOTAL
RALPH D BOWES �
� D B. 219, P 332
�� 1
m N
O Uj
e v
O �
Z 1. 00 ACRE
IS N83•Sg•?B"N
300. 00'
. �