A23 156z
, Person County Health Department �
•� Sewage System Improvements Permit
Date: 2�' s ermit oi� ter 5 Ye�cs Permit # �
Owner• , d�� ��/5 0 �v G S ,� y; Pv s SR# 2
Subdivision ame: � � - Lot #�- `�
Lot Size: 4-C- Type of Dwelling:
Water Supply: Private: Public: Community:
Bedrooms: Z Gazbage Disposal
Basement Basement F' tures
INFORMATION CERTIFIED B
Environmental Health Specialist� � owner or representattve
REPAIIt: REEVALUATION:
-------------------------
Size of Septic Tank: gallQns Size of Pump Tank:
Nitrif'ication Line: Oa � X � /
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks: �+ � 1
Date Well Approved: Well should be 100 ft from any sewer system
BY Environmental Health Specialist
D Sewa�e System App v. ��
BY Environmental Health Specialist
CERTIFTCATE OF COMPLETION ,.�
Contractor. �-� � - �
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Sewage System location, instaliation, and protection must meet state and local �
regulations. Septic 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 �
nitrification 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 sub,ject to revocaiion. �)
(G.S. 130 A-335F) ,
x
Location of sewage disposal sewage system sketched on back. �
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(OVER) oC�
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T�TOTE: Make sketch oi installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installation� may be located
at later date. Note location of water supplies on adjacent lots.
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Amount paid �'I '� � b ��' ��
Receipt .�� � 6z Date
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. C� AP�'LICATION �'OR S�RVICCS , z;<,�
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Chemical Petroleum _ Pesticide _ ea
_ Bacteria —
Permit requested by: .
ner/prospective owner/agent� 2r'e �`�-S
dress: ��G--� �4` �ou-'e 5 �-�
ome Phone #: ��"1�` S� �
usiness Phone #: Si'l '•-04 s�
Name and addre�s of current owner:
. Property Description: Lot size: i a c�'-e-�
Tax Map#:_._��
Parcel#: � � 5
Township:�ir�
Directions to property: State Road #& Road
ames. etc. ., 1
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a?� � P�t`� s a� S
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7. Dimension�or Proposed Structure:
Width: �
Depth: �
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal s stem is intended to serve?
I (��- Q `,� c.e �M �,� � h.� +�-�--
9. Water supply t}'pe:
private �public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No �'
If so, identify location:
I0. Type of structure/facility: Proposed: �Existing: Q
Type of dwelling:
House: (�Mobile Home: [� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: `� _
Garbage Disposal? Yes ❑ No Cl
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 STRUCTURES.
I hereby make application to the PersOn COIIit�y Health Department for a site evaauali�ation ahe �e ite
sewage disposal system for the above described property. I agree that the contents of this 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 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 pro erty to the Heaith Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this pplication shall become void and all fees paid forfeited.
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Permit Issued ❑
Permit Denied ❑
Plat Observed ❑
Signature
Date � •
�AG�bRS$TfE �VALlJA�70if.> { a .`' .....-: _ � e : c' , x71+RF1i i ., « < . ARFJ12 r ARFt.3' ., x r.: j�RFAd $.'> � >.. y::
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1. SLAPE (%) S S S S
PS PS PS PS
U U U U
2. SOII.iF�C7lJRE(12-36IN.) S S S S
(SANDY, I.OAMY, CIAYEY. NOlE 2:1 CtAI� PS PS PS PS
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1. SOiL ST7tUCiURE (12•S6 IN.) S S S 5
(MYEY SOfI.S) PS PS PS PS
V U U U
3. SOILDFp'IFi(IN.) S S S S
PS PS PS PS
U U U U
S. RESiR]C17VE HORIZONS (IN.) S S S S
(IMPFRVIOUS STRATA. ROCK) PS PS PS PS
U U U U
6. SOI[.DRAINAG&GROUNDWA7ER S 5 S S
(FJCCE7tNp(, & INTERNp1,) PS PS PS PS
U U U U
7. SOILPERMEAB1117Y 5 5 S S
(PERCOLAATION RA7E� PS PS PS PS
U U U U
E. AVAILABLE SPACE S S S S.
PS PS PS PS
U U U U
9. SCIECLASSIFICA170N(SEEBE[.OV1�
SOIL SERIES '
S-SUITAIILE PS.PROVLS70NALLY SUCfA6l.E U-UNSUifABLE
RECOMMENDATI ONS/COMMENTS:
QTTF C'T .A C.CTFTC'ATTr1N T1TAl:R AM (Tnclucie� Soil areas, oro�ertv lines, roads, streams, Qullies, wet areas, fll
.
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R.B. DAWES, JR.
c.a. n3, P. 632
IS
LONTROL -
CORNER ..
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ACRE
R.B. OAWES.IR.
O.B.173. P 632
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/NS � PROPOSED SO' o ^°
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, RALPH D. BOWES � � IS
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Yerson County Health Department
Existing Sewage System Report For: VMobile Home Replacement .`��"
Addition
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Requestee: �/'1 � Lc�C
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Location/Directions: ��_�'�et� S �,
�l2 �:lnG. �n u� c � . �s� `�
Home Phone# �� %- J75 )
Business# � ��`b�5(�
Tax Map# � ��5,�
�2 C ,� �_ Sc,� Cl�. ,�gf
�c�.� �l� L�►�-�. � -
Original Permit Located 1/
Septic System Uesigned For: -
ktesidential V Business Other (speci�y)
# Hedrooms �- _ # E;mployees Other
0 /,,
llate lnstalled S�a� 3�� �f� Water supply �
`Pype of System ��i1 ✓��i`(7Y1 �j
Nitrification Line �� � )( ��
Tank Size
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Certified Operator Required ��
On site wastewater disposal system showes no visually apparent
maltunction on /b o'?%-�l7
Yermission is granted to: il_��SQ. ���1 �1�1.�.7P_S
According to the attached site plan.. -
C o mm e n t s: �%r �,� ,/.i f'���t )-Q _ • �Q/ ���,t.�,QJ�
., _' ,1 ' A _ � .. � .7 _ . c , � .,n � /] ._ _ n _ � �. /%
Environmental Health Sup . f� /'7
DATE
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT.
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 # A Z � Parcel # ���
Zoning Township � ,�, � ; d) vY�
Owner/Contractor c�� ��� Da � � I l� ( �i `7
T c�catinn/Arlr�rPcc I/Vlr i i_ o o �' � : l 1 � /� �� � ���SL[_.5 �� ��Q �i
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Subdivision Name
���,(�_ S.R.# /363
Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area �,�_� Size of Tank � C ; 5-E-: — O �
SFD ,/ � Mobile Home �/ Size of Pump Tank N�,q.
Business # of Bedrooms Nitrification Line ��dl ���"— S�co'Mm _
Max Depth Trenches ��' X 3�
�T,��,= • �"I
Permits may be voided if
Well and Septic Layout by_
Comments: `�����C � n
is altered or intended use changed.
Date !O -�9- 9� Installed by Approved
��
ell Permit Paid ❑ WELL SYSTEM SPECIFICATIONS
3ividual emi-Publi
iblic Replac e t
te Approved
ell Head Appr
-outing Approved
Comments:
Date
Installed by.
Required
Well
Approved by.
�a�f319�
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 enviro�mental 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 enviroamental 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: l O— 1�—�J'� IlVIPROVEMENT PERMIT #: 13 � g g`1
TAX MAP #: 3� PARCEL #: j
OWNER�OWNER�S REPRESENTATIVE: ��2c—e5c� ��� �5
LOCATION/ADDRESS:
2-� � S �'(��� �,� �� �
� - I `�• ' 7�� � �. �i ' • •
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SUBDIVISION NAME:
SECTION OR BLOCK: � " / '
. AUTHORIZATION FOR CONSTRUCTION ISSUED BY:
AUTHORIZATION CONDITIONS
�
LOT #:
1. The Wastewater system constcuction and installation must meet all of the conditions of the
attached site plan and specifrcations as set forth in Improvements Pernut # 4 S The
construction and installation must also meet alI applicable n.iies 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 stcucture 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:
Person Requesting: