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A23 152�4��'�?�rson County Health Department ��-- � ! Sewage System Improvements P�Hmit �' Date: %2 /� —`�/ This Permit Void After 5 Years Permit #� �c�� Owner: D r11 r, v 1d � SR# �� Location/Directions: . Subdivision Name: '� Lot # Lot Size: E Type of Dwel ' g: Water Supply: Privaie: � Public: Community: Bedrooms: � GarbaSe DisPosal � . Basement Basement Fixtures � �� • INFORMA�� BY _ . S8I11l8118I1: �� o tative REPAIR: REEVALUATION: Size of Septic Tank: �.gallons Size of Pump Tank: Nitrification Line: / / Depth of Stone: 12 inches � Max Depth of Trenches: Altemative System: Conv. Pump LPP Pump�-- Remarks: � _ ,� , / ' � Date Well Approved: Well should be 100 � BY Sanitarian Date Sewage System Approved: BY Sanitarian CERTIFICATE OF COMPLETION Contracwr. _�' e /d �'�! 6� any sewer system Sewage System location, installadon, and protection must meet state and local reguladons. Septic cank 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 Department before any portion of the installation is covered and put into use. If the site plans ar intencied use change this permit is subject to revocation. (G.S. 130 A-335F) Location of sewage disposal sewage system sketched an back. (OVER) N01'E: Make sketch of installati showing lot size and shape, location oi house, septic tanks, privies, water � supplies, etc Note s ial le �'s�jng on lot. Write in measurements in order that installations may be located '` tit later date. te 1 w te ' s on adjacent lots. �1) �2� - _- �'�:rson �ounty Health Department � Well Permit d f � 12- / � .�.•� a Date: �• I Triis enu� Void After 3 Y s Owner: '1'"o m rn �/ �, SR# /.3�•� Location/Directions: Subdivision Name: Drilling Contracwr. Distance from Nearest Ptnperty Pll ' l�v �1w�5 Lot # WELL CONSTRUCTION Line��s Distance from Source of o unon � Total Depth:��. 7tield: ��GPM Stadc Water Level �d F� Water Bearing Zones: Depth Ft,�� Ft. Ft. Ft. Casing: Depth: From _,Q_ co �! %� FG Diameter: Inches T'YPE: Steel GaI�—aruzed Steel ti If Steel, does owner approve: Yes No _- We�g}lt ��— Thiclmess: Height Above Ground: ��_ Inches Drive Shce: Yes �� No Were Problems Encounteted in Setting the Casing? Yes No �— If "yes" give reason: Grou� Type: Neat Sand/Cement `�Concrete Annulaz Space Width =3 Inches Wacer in Armular Space: Yes No �� Method: Pumped Pressi:re Poured �-� Depth: From fl to F� MCa�/te�rials Used: No. Bags Pordand Cement � Weight of 1 bag � Ibs. If mixture (sand gravel, cuttings) - Ratio: �_ to �_ ID Plates: Yes �a 4 z 4 slab Yes No � s� k � � b c� I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT � 'THIS WELL WAS CONSTRUCfED IN ACCORDANCE WITH REGULATIONS SET ,Y FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. �k �-%-�-'� (�/�D�,1�.T I Si of on Date i��7 D anitarians SignaNre Dau Issued Sanitarian's Signature Date Complete� Sketch well locadon on reverse side. .. � Site Evaluation Application Fee Collected YES � NO �7� 1 Z-l�- 2/ � Date : �� APPLICATION FOR IMPROVEMENTS PERMIT 1. Permit requested by: owner/prospective Address: Home Phone ��: 2. Name and address of current owner: t: � / � f. t� sines— h ne �: 3. Property Description: Lot size: � 4. Tax map 4�: Township: C Lc Subdivision Name: � Lot ��: � 5. Directions to property: State ijo�d �� & Road,Names, etc. 6. Permit requested for: New Installation: v 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: 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 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 35(F) igne er or Author zeci Agent z � m H w x � w m r 0 rt � b � n � I N. r+ � Permit Issued � .��_ Permit Denied Plat Observed � O�� , S�� j�� . : � ��'ACTORS — SITE EVALUATION AREA 1 AREA 2 AREA 3 AREA 4 1. SLOPE (X) Z. SGiL TEXTURE (i2-36 in.) (SandS, Ioamy, clayey, Note 2:1 clay) 3. SOIL STRUCTURE (i2-36 in.) (Clayey soils) � 4. SOIL DEPTH (i.n. ) S. RESTRICTIVE HORIZONS (in., (Impervious Strata, rock) 6. SOIL DRAZIIAGE/GROUNDWATER (bcternal & Internal) 7. SOIL PERMEABILITY (Percolation Rate) PS S S S . � S U S S PS S S PS �T S PS U S PS U S PS U S PS U S PS U S PS U S $. OTHER (specify) PS PS PS PS � u u u u 9. SITE CLASSIFICATION (See below) SOIL SERIES S- Suitable PS - Provisionally Suitable �..0 - Unsuitable _ �tECOMMEIdDATIONS / COI�4iEriTS : ��TE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, Wet areas, fill areas, wells, water bodies, slope patterns, etc.) � � � w U � a W � z OU Amount paid �`��•�— Receipt i� ' 1�3d l�-� ,��oo a.v59 � l�-1�-98 Date ments Permit. (Established/Recorded Lot) �_ Reinspection of Existing System (Loan Closing) ImpFovements Permit (Unrecorded Lot) Improvements Permi[ (Mobile Home Replace) Improvements Permit (Addition) - Repair/Replace existing Septic System _ Permit for New Well _ Replace Existing Well 1. Permit requested by: . �wner/prospective ownec me Phone #; usiness � 5 5°77-�77 � '� �l � q� s_ z- � G�,3 cp MP Name and addre�s of:current owner: Property Description: Lot size: � � %Q �C- Tax Map#: �f,�7.� Parcel#: f .J2 Township:_ �� h.� _ _ . Directions to property: State Road #& Road f ames,�tc. : � -� i� s �u��..� �,..._ ,�� . � r�..., k l. ��2 d y�--� � G. f g G'.o� Number of occupants or people to be served: � 7. Dimensi s� � Proposed Stcucture: Width: � T)enth � S 3 ° 8. What type (if any, additions, expansions, or replacement is anticipated to the structure or facility that ihis sewage disposal system is intended to serve? 9. Water su�ply t�•pe: private �public ❑ community ❑ spring Are any wells on adjoining property?Yes �No [�. If so, identify location: 10. Type of structure/facility: Proposed: DExisting: Q Type of dw�ell' g: House: L� Mobile Home: C� Business: ❑ Type of business: Number of Employees: Number of bedrooms: _..�_—/ Garbage Dispos�al?�' es ❑ No [�' iBasement? Yes L�' No�.7 If so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the PCI'SOn COunty Health Department for a site evaluation for the on-site sewage disposal system for the above described property. I agree that the con�ents 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. I understand [hat before an Improvements Permit 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. within 60 DAYS after the date of the evaluation of the site by the Health Dept., this application shail become void and all fees paid forfeited. Owner or Authorized Agent � w � a 2664 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IlV�'ROVEMENT PERMIT Not for waste water system construction. No permit(s) for Construction Location or Relocation Activity shall be issued until Authorization for waste water system construction has been issued. Tax Map # � Zoning Owner/Contractor `��} n'1 �l Location/Address 5`� �U �`��I Q �� -�� . k n-t— /� ��-� _�,_ V�. I 1.. Subdivision Name Parcel # � �� Township / L,-�-�,(��, ate �— 2 I- Q�j 1 f e✓3 Y'1 �(\/�i � ii�t�Y\ IQ(�Y �l i� �ii, ii c � i I� l(/Jl Lot# SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area j��'Ci SFD � Mobile Home Business # of Bedrooms� Permits may be voided if site is Well and Septic LayQut by_� Comments: �.� or Size of Tank /�JL! Size of Pump Tank Nitrification Line t Max Depth Trenches � �1�( �i� � l% nded u�,e chan�ed. Date Z-�Z�—OD Installed by �, ,U (�i Approved by Well Permit Paid ❑ WELL SYSTEM SPECIFICATIONS Individual Public Site Approved Well Head Ap� �� Grouting App Comments: Date Semi-Public_ Replacement Installed by Required Slab _ Air Vent Required Well Log Well Tag Qi S.R.# [� 1 .i..t -�� %��S � 1%nn��rc�u This report is based in part on information 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 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 to 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 O1/95 rev.l.l AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (Void sixty (60) months from date of issuance) DATE: �—a�— �� Il1�IPROVEMENT PERNIIT #: a% TAX MAP #: Z3 PARCEL #: `!j'Z OWNER/OWNER'S REPRESENTATIVE: �� O:_.� LOCATION/ADDRESS: SUBDIVISION NAME: t�, LOT #: � SECTION OR BLOCK: . AUTHORiZATION FOR CONSTRUCTION ISSUED BY: ra n . CONDITIONS 1. The Wastewater system construction and installation must meet all of the conditions of the attached site plan and specifications as set focth in Improvements Pernut # ��,��-. The construction and installation must also meet all applicable niles 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 permits. b Su�� a��l��,za. �h��. � �� =� � w �� +�. s� I � � Application #: Tax Map #: ' `�-.3 Parcel #: /S'�oi--- Person County Health Department Environmental Health Section SITE SKETCH �" � � � 1 � � Appli nt's Name Subdivi 'on/Section/L . a3 �ao , �- A horized State Agent Date System components represent approximate contours only. The contractor mustflag the system to beQinnin,� the insta[lation to insure tliat 25� � Scale: is ma�ntainea. v PCHD, rev. 10/12/99 m � Q� ` �� S� P�� f l l QkTvIU�'( ``l �c�%i�� Application #: �r`l,��r, Tax Map #: Parcel #• j�� Person County Health Department Environn�ental Health Section SITE SKETCH �� ;d �� A licant's Name Subdivi� on Section/Lot# _ S 2'z3 � thorized State Ag nt Date System components represent approximate cnntours only. The contractor must Jlag the system to beQinnin� the insfallation to insure that proper graue rs ma�ntainec� G � r �0 L�K.� . [• � PCHD, rev. 10/12/99