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1. Permit requested by: (��¢k/�,v� �—� 7. Dimensions or Proposed Structure:
�wner/prospective owner/agent: G � �� Width: �
w a.�__..... Tlar�th• �/'
, � 8. What type (if any, additions, expansions, or
' replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
ome Phone #:
usiness Phone #: _ ��l'G'I �
Nam and address of current owner:
��_1�'IPS `���rjr/�.�I�- ,
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Property Description: Lot size:
Tax Map#: ' 3
Parcel#: d
Tnwnchin• [//I/i{/i%�/l/ �%'/�"'
Directions to property: State Road #& Road
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. Number of occupants or people to be served: ��
Water su pe:
ivate public ❑ community ❑ sprin',�g ❑�
�e any wells on adjoining property?Ye�'1vo ❑
so, identify location: ti
10. Type of structure/facility: Proposed�Existing: ❑
Type of dwelling:
House: Q' obile Home: ❑ Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �
Garbage Disposal? Yes ❑ No �—
Basement? Yes ❑ No ❑ 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 Pet'Son COunty Health Departmeilt for a site 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. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the proper[y 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 shall become void an�ll fees paid forfeited.
Si�d Owne`r or �iuthor�d Agent
Permit Issued u
Permit Denied ❑
Plat Observed ❑
l. SLOPE(R)
SOIL TEXNRE (12-36 IN.)
4NDY. LOMiY, CLAYEY, NOTE 2:1 CLA1�
SOiC. S7RUCIURE (12-361N.)
LAYEY SO[LS)
SOIL DEP'I'H (IN.)
RESTRICi]VE HORIZONS (INJ
APERViOUSSTRATA.ROCK)
SOIL DRAINAGFJCROUNDWA7ER
XTERNAL & INTERNAL)
SOIL PERAtEABILTiY
=RCOLOATION RATE)
AVAILABLE SPACE �
SITE CLASSiFICATION(SEE BELOW)
tL SERtES
RECOMMENDA'
Signature r � ' �----- �r �� —.= Date
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SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.) C:NMiPRO�DOCSUPPSEC.SMflNANCE.PC
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Subdivision Name i�a-K Pc� i�P
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I.ayouc
`�-� t{au�
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Con�oc�� ,�,�
MaX� -rrer,c�
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SPECIFICATIONS
0
Repair Lot Area / �`/'� Size of Tank / L�1��1
SFD � Mobile Home Size of Pump Tank /DD��
Business # of Bedrooms�_ Nitrification Line l��f�' X�
Max Depth Trenches `
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is alt red o intende�, e nged.
Well and Septic Layout b � v� �
Comments: r'' � ` - a37 �
Or�o! �'v t,���. -%�_ CoJ�� TGnl�c �' D�A�
by 'T .�,�J � S Approved by
ell Permit Paid C�" WELL SYSTEM SPECIFICATIONS
3ividual ✓ Semi-Public Required Slab
�blic Replac ent Air Vent �
te Approved Required Well Log
ell Head Approved Well Tag 1�
•outing Approved
0703
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environmental health specialist is not responsible for false or mis(eading 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 Counry nor the environmental health specialist warrants that the septic
tank system will continue to function satisfacrorily in the future or that the water supply will remain potab(e. c:�amipro\permit.sam 01/95 rev.1.0
P�RSON COUNTY ENVIRONPfEA'TAL HEALTH
. � , .
< ' �` � tdELL LOG
Date: _ 8 9 '
Owner: �-;�- Mc-('nll,�m
Location/Duections: �' Pointe r�ot #� o SR#
�ubdivision Name:
Lot # !D
Dnlling Contractor: Virginia �Well DRilling
WELt, CONSTRUC'TTON
Distance from Nearest Property Line Distance from Source of
Pollution
Total.Dep.tti:. 155' Ft. Yield: 40 .. GPM St2iic :Wat�r I,ev�l :: 6o Ft:
Water Bearing �ones: DePth � . Ft. .� F� - Ft Ft.
Casing: D.epth: � From o �to 47 Ft. Diameter: 6 Inches
TYPE: Steel - Galvanized Steel X
- If Steel, does owner approve: Yes X No
� Weigh� � � 3 Thickness: � 88 ,Height'Above Ground: � 2 Inches
I?iive Shoe: Yes X No �
Were Problems Encountered in Setting the Casing? Yes� j�to X
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It yes" give reason: . .
Grout: Type: ' Neat -- ' SandJCement X Coricrete
Annular. Space Width 13 Inches
Water in Annular Space:- Yes No X -
Method: Pumped Pressure Poured x .
Be� �: From - o to 47 rt. -
Materials Used: No. Bags Portland Cement Weigl-it of .l bag�_lbs.
If mixtuie (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes x No � �:. �
� 4 x 4 slab Yes X No -
� � DRILLTNG L4G _
� �----7 - - - - - - -
- � Fram
12
- 47
To
- 12
47
155
- rormation Descripti
- Red Clay
Brown Dirt
Granite -
m - --
I HEREBY CERTIFY THAT THE ABOVE I�tFORMATION IS: CORRECT AND THAT
T�S WELL WAS CONSTRUCTED 1N ACCORDANCE WITH REGULATIONS SET _
FORTH BY_•THE PERSON GOUNT�':HEALTH DEPARTMENT. -
- d � 9 .
Signature of Contractor - ate �
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PERSON COUNTY HEALTH DEPAR � MENT
SUBSURFACE WASTEWATER SYSTEM MONITORING REPORT
Date Requested (w/fee): �� �� Property Owner: ���� � e �`%l C- ���
Tax Map/Parcel: /� ���� Phone #s: 3 3 6�3 �{q - 3�k 7 6 Schedule Visit? Yes_ No /
Property Address:
�-I�f -�r/
Date of Inspection
86 �ov.� OoK Cove �ir.
6—�z-1 R w7 �
System Installation Date System Type
� e.�t,l,o r a� 1�l C o2. 7 3� 3
V� �-t �VY
rtal Health Specialist
Instructions: Check yes or no for appropriate items and explain in space provided for remarks and comments. If an item is not
applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate by "N" and explain. Note that this monitoring form is
not totally inclusive for all systems. All maintenance and monitoring items specified in the permit are to be carried out.
INSPECTION RESULTS
COLLECTION SYSTEM:
Evidence of leaks ?
Tank risers accessible, free of
infiltration and surface water diverted ?
Septic tank needs pumping ?
Inches of solids:
Septic tank filter cleaned ?
YES / NO
❑ �
❑ � ❑ 'v
❑ � ❑ _
EFFLUENT DOSING SYSTEM:
Required pumps present & functional ? � / ❑
High water alarm operating properly ? ❑/❑ 1�
Floats, valves, etc. in good condition ? "� /❑
Control panel & components in good
condition ? � ❑
Effluent free of excess solids ? ,� �❑
Inches of solids(pump/dose tank): L 3
Elapsed time readings ? h q
Counter readings'! �` S
Drawdown rate: O C.�
DISPOSAL FIELD:
Evidence of effluent surfacing ? ❑
Evidence of effluent ponding in trenches ?❑
Surface water effectively diverted ? '�
Diversions/swales properly maintained ? ❑
Vegetative cover maintained ? �
Protected from tr�c/unauthorized uses ? �
Distribution devices in good condition ? �
Field free of settled or low areas ? '�
/
/
/
/
/
/
/
/
REMARKS
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PRESSURE DISTRIBUTION SYSTEM:
Tumups/cleanouts/valves/taps intact &
accessible ? ❑ � ❑ k� 0 �] _ i � ,� ► ✓f I� �r; �! � �'�Q ` � • ,�
r1�1 /•4
Pressure head properly adjusted ? ❑ /❑ yt�p� ✓1��
COMPLIANCE:
Compliant
Non-compliant
Needs Maintenance
ADDITIONAL COMMENTS:
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(4/13/16)