A23 151.._ • z
Person County Health Department �
��evsage System Improvements P�_!� �
Date: ' Permit Void ter 5 Years Permit # I�
Owner:
� � 4�� Gt C � SR# �'► •
Location/Dir tions: l�►c t ��� j ch
_. ;�l � n l� �.U,��..,
Subdivision Name: Lot # L
Lot Size: Type o welling:
Water Supply: te: Public: Community:
Bedrooms: � Gazbage Disposal
Basement = Basement Fixtures , /
INFORMATION CERTIFIED BY C�"`�� �/'L
Environmental Health Specialist: er�qc-�re��r�a�e
REPAIR: R�EVAL ATI tl
,.._
Size of Septic Tank: /Il
Nitrif'ication Line: �
Depth of Stone: 12 inches
Max Depth of Trenches:_
Altemative Systemr� / .
Remarks: _1�'
gallons Size of Pump Tank:
� �'F" .� �
LPP
Date Well Approved: Well should be 100 fk from any sewer system
BY Envir nmental Health Specialist
Date S age y m rov • _
BY Environmental Health Specialist
�,OF �,.�
Coniractor. �^ N �� f �
------------ -----Sno� ��.�-- �
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Sewage System location, installation, and protection must meet state and local �
regulations. Sepdc tank should be pumped out every 3 to 5 yeazs and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and
nitrifcation 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 pennit is subject to revocation
(G.S. 130 A-335F)
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
� Person County Health Department �
Well Permit �
Date: �' This P rmit Void After 3 Years , ��� °f
Owner• ./1 V i C• M c V� v��oSU �; SR# �.3
Locaaon/Directions: . . �`T`r�'. ,�. : ,
Subdivision Name: 2 C Lot #�_
Drilling Contractor. IL��1 �
W
Distance fro Nearest Property Line Distance from Source of ._
Pollution � "'s
Total Dep : G Yeld: �GPM Static Water Level ��FG
Water Bearing Zones: Depth Ft � Ft. FG Ft.
Casing: Depth: From 12_. to �_ FG Diameter: J' Inches
TYPE: Steel Galvanized Steel ��
If Steel, does owner approve: Yes No
Weight: .�.._ Thiclrness: Height Above Ground: T��. Inches
Drive Shce: Yes No
Were Problems Encouncered in Setting the Casing7 � Yes No "--
If "yes" give reason:
Grou� Type: Neat Sand/Cement Concrete
Annular Space Width 3 Inches
Water in Annular Space: Yes No ��
Method Pumped Ptessure � Poured �---�
Depth: From �— � FL � _ .
Mat Used: No. Bags Portland Cement �_ Weight of 1 bag
� lbs.
If mixture (sand �a��� No - Ratio: _� to �__
ID Plates: Yes ,
4 z 4 slab. Yes � No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AIv:. Taa'i
'THIS WELL WAS CONSTRUCfED IN ACCORDANCE WiTH REGULATIONS S
FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT.
Date
Date Issued
Sanitariaris Signature Date Completed
Sketch well location on reverse side.
.
Site Evaluation Application
FeekColiected YES v NO
�� /2 _�,� -��
Date : ��������
� APPLICATION FOR IMPROVEMENTS PERAiIT
1. Permit requested by: owner/prospecti�
_ � _ agent:
Address: /,�� O
Home Phone �r : ��
2. Name and address of current owner:
Business E'hone ��:
0
3. Property Description: Lot size: i t�
4. Tax map ��: Township: ��� ,��
Subdivision Name: �'�,t ,�nfo���,c� Lot �F':
5. Directions to property: State Road �� &,Road Names, etc.
,
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 property?
community? __ spring?
�
If so, identify location:
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 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. 130 35(F)
S' gn cU er',�o A orizen Agent
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Yermit Issued �
Permit Denied
Plat Observed _�/
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FACTORS - SITE EVALIIATION AREA 1 AREA 2 ARE� 3 AREA 4
S S S S
�.. SLOPE (X) PS P PS
' yT .-._
2. SGIL TEXTURE (12-36 in.) S .� S .
(Sandy, Ioamy, clayey, S P PS PS
Note 2:l clay) U U
:3. SOIL STRUCTURE (12-3b i.n. ) S S S S '
(Clayey soil.$) � p p pg
4. SOIL DEPTH (in.)
::>. RESTRICTIVE HORIZONS (in.)
(Impervious Strata, rock)
6. SOIL DRAIAIAGE/GROUNDWATER
(bcternal & Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
U
S
U
S
S
S
PS
U
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U
S
S
U
U
S
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
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8. OTHER (specify) PS PS PS � PS
• U U U U
9. SITE CLASSIFICATION
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable �..0 - Unsuitable
`tECOt-�SEIIDATIONS / COI II,fErITS :
�ITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies,
wet areas, fill areas. wells, water bodies, slope patterns, etc.) '
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��July, 1992
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H,�o�ake Ernest B.Wood,Jr
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LIA= B£ARING DIST. plat •
L-1 N 73-18-23 E 67.90 actua
L-2 r: %?-18-23 E 57.F9 r�«�-