A23 150�
. Site,Evaluation Application Date
Fee Collected YES v NO
p� Iz-l�- rl
�j APPLICATION FOR IMPROVEMENTS PERHIT
1. Permit requested by: owner/prospective ner: _L
ent•
Address : p � yyj�j� S.�
Home Phone ��: b Business Phone �:
2. Name and address of current owner: C�- �
3. Property Description: Lot size: i �
4. Tax map ��: Township:
Subdivision Name: � . Lot 4�:
5. Directions to property: State Road �� & Road Names, etc.
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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.
11,
Water supply private? �/public?
Other source? (Specify):
Are there any wells on adjoining propert
community? spring?
If so, identify location:
Type of structure or facility: roposed: Existing: —
Type of dwelling: House: Mobile Home: Business:
Type of business: Number of Emgloyees:
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 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- 5(F)
/���,�.��-o - .
gne er or uthorized Agent
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Permit Issued
Permit Denied
Plat Observed f/
��'.�CTORS - SITE EVALUATION AREA 1 AREA 2 AREEI 3 AREA 4
S S S
J. SLOPE (X) � S� PS
�T
?. SGZL TEXTURE (i2-36 in. ) S S . S ,
(Sandy, Ioamy, clayey, PS PS ^ PS PS
Note 2:I clay) U � U
3. SOIL STRUCTiJRE (12-3b in.) S S S '
(Clayey soils) � 'P PS P� PS
4. SOIL DEPTH (in.)
S. RESTRICTIVE HORIZONS (in.)
(Im�ervious Strata, rock)
6. SOIL DRAIIZAGE/GROUNDWATER
(bcternal � Internal)
`I. SOIL PERMHABILITY
(Percolation Rate)
S
PS
U
S
YS
U
S
PS
S
S
S
S
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PS
S
PS
U'
S
S
S
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
8. OTHER (specify) PS PS PS � PS
• U II U U
9. SITE CLASSIFICATION
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitabie �..0 - Unsuitable
:.ECOt�R4EIdDATIONS / COr�R IErITS :
,sITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies,
wet areas, fill areas, wells, water bodies, slope pat�erns, etc.) �
.
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PERSON COUNTY HEALTH DEPARTMENT
r WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # � .� 3 Parcel # ���
Zoning Township - � �m
Owner/Contractor �a Yo � e e - -
Location/Address nl�.� to I � �� �� �< �..� 6�
P ✓'1 tl� �.� d 'th✓V NeY� �ffiY9ov e �� lsF Ief-� (�f- I^ . f ^`'' .R.� l� I �
Subdivision Name Lot#
co
.Layout
�C� LY
Ar�
v.�,Lct f�y co
As Installed
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SEWAGE SYSTEM SPECIFICATIONS
epair Lot Area (� D� Q��S Size of Tank�Q
FD Mobile Home Size of Pump Tank Nr
usiness # of Bedrooms�_ Nitrification Line_�
Max Depth Trenches_
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Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altere�-�ir in;t�cr��d us c�, hanged.
Well and Septic Layout by �7����2i� ��
te � - Installed by J� �e.��S Approvec
� ° °- �=�' b
ell Permit Paid WELL SYSTEM SPECIFICATIONS
Individual ��Semi-Public Required Slab �
Public Replacement Air Vent i�
Site Approved Required Well Log
Well Head Approved Well Tag
Grouting Approved
Comments:
Installed by r�►� �, Approved by,
0932
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this pertnit. 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 report that may have resulted from false or
misleading statements provided ro him in the application. Neither 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 01/95 rev.1.0
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� Date: _ /T �- �c-S�
Owner:
Location/Directions:
�ub?ivision Name:
Drilling Contractor: _
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P�RSON COiJNTY ENVIRONP��:NT��L iiI:ALTH
WLLL LOG
� r/ G /^s/ ]4—� e� /TI
Distance from Nearest Property Linc��,s��,,, � Distance from Source of '
Pollution 0 � u,,r �
Total.Dep.th: ' Ft. Yield: �S' GPM Static Water Level Ft.
Water Bearing Zones: Depth - 2y� Ft. Fc. - Ft. �t.
Casing: Depth: From_ �'� to_____,�c�Ft. Diameter: �� Inches
TYPE: Steel � Galvanized Steel � �
If Steel, does owner approvc: Yes No
� Weigh[: � f.3 Th.ickness:��, Height Above Ground:� L Inches
Drive Shoe: Yes �—'" No �
Were Problems Encounterecl in Setting the Casing? Yes No e�
If "yes" give reason:
Grout: Type: Neat Sand/Cement �- Coricrete �
Annular. Space Width 3 Inches
Water in A.nnular Space: Yes No �-- �
Method: Pumpeds� Prc:ssure Poured c_..-
Dcpth: Fram_ to �-d Ft.
Materials Used: No. Bags Portland Cement Weight of .l bag�_lbs.
If mixtui-e (sand, �ravel; cuttinas) - Ratio: to
ID Plates: Yes � No � � :. �
� 4 x 4 slab Yes ✓ No �
Z HEREBY CERTIFY THAT THE A.BOVE INFORMATION IS CORRECT AND THAT
T�S WELL WAS CONSTRUCTED iN ACCORDANCE WITH REGULATIONS �SET
FORTH By�T�-IE PERSON COUNTX �-IEALTH DEPARTMENT.
� �✓ �� �� 6
Signature of Contractor Date
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