A23 94�/ N'�r�on County Health Department z
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Sewage System Improvements Permit
Date:7 l/ ,�.This Permit Void After 5 Years Permit # �
Owner: ����• Pn �r '��..� SR# —�``� S�
Location/Directions: .�
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Subdivision Nam o � °'� r•, � � o ^ � ,..�rc �t #
Lot Size: `-+ Type of Dwelling: �1�/,
Water Supply: Private: Public: Community:
Bedrooms: ___,�.� Gazbage Disposal �
Basement Basement Fixtures
INFORMATIQN D BY
Sanitarian: � !'L er w representative
REPAIR: REEVAL ATION:
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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:
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Date Well Approved: Well should be 100 f� from any sewer system
BY Sanitarian
Date Sewage System Approved:
BY Sanitarian
CERTIFICATE OF COMPLETION ,.�
Contractor. �
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Sewage System location, installation, 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 czeate a public health hazard. Septic tanlc and
nitrification line must be inspected and approved by a member of the Person County
Health Departrnent before any portion of the installation is covered and put into use. If �j
the site plans ar intended use change this pemiit is subject to revocation. �
(G.S.130 A-335F)
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
. NOTE: Make sketch of installation showing lot size and shape, location oi house, septic tanks, privies, water
� supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
� at later date. Note location of water supplies on adjacent lots.
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Improvement Permit
� 1. Permit requested by:
Address : � �CJ � I�
APPLICATION FOR:
( ) Subdivision
2. Name and address of current owner:
Date Received: / �a `�
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Home Phone'" `% ( . ( "
Business Phone �G!
3. Property Description: Lot size ����� Dimensions:
Front Left Right Rear
4. Tax map No. Township: Block No. Lot No.
5. Directions to property: State Road No. & Road Names, etc.
6. P�rmit requested for: New Installation � � Repaired
Additional Renovation re-using present system
7. Number of occupants of people served�
8. Dimensions of Proposed Structure: Width Depth___��
9. What tyge (if any) additions, expansions, or�replacement is an�icipated
te the structure or facility that this sewage disposal sys�em is intend
to serve?
10. Type of water supply: Well�yes no: If r.o, name source of water
supply: Are there any wells on adjoining
property? If so, identify location.
il. Type of structure or facility: Proposed Existing
. Type of dwelling: House Mobile Home_� Business
Type of business Number of Employees_
Number of Bedrooms Number of automatic appliances_�
Basement Number of basement fixtures
12. Clearly stake all corners of the property snd the corners�of all p
structures.
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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 conten
of this application are true and represent the maximum facilities to be .d
placed on the property. I understand that if any changes are made without ,�Dy
approval from the Person County Health Department, the permit will be void. N.
Any permit for a system is non-transferable without prior approval of the �
Person County H�alth Department. Permits are valid for �! months from dat '�
of issue.
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SIGNED
FACTORS - SITE EVALUATION
1. SLOPE (X)
2. SOIL TEXTURE (12-36 in.)
(Sandy, loamy, clayey,
Note 2:1 clay)
3. SOIL STRUCTURE (12-36 in.
(Clayey soils) �
4. SOIL DEPTH (in.)
5. RESTRICTIVE HORIZONS (in.
(Impervious Strata, rock)
6. SOIL DRAIAIAGE/GROUNDWATER
(bcternal � Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
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9. SITE CLASSIFICATION ---
(See below) '
SOIL SERIES --
S- Suitable PS - Provisionally Suitable U- Unsuitable
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies,
wet areas,.fill.areas, wells, water bodies, slope patterns, etc.)
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PERSON COUNTY HEALTH DEPARTMENT
t- _ . 3
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # ,/-} 2 3 Parcel # � � ' � '
- � Zoning Township
Owner/Contractor �.�� �1 �,� . � Date % _ 1 !_ �i /
T.nr.atinn/Ac�riresc i ✓.'�r I 2 ? ? ._�r, �/%fl' / 27� 7�'D ���' .a�o;r��wi�e.
%�o�,� on L.� �' -� ! n<-� �1 �,` J� f� i,; �-e `"s/� S.R.# � 3Z 2
Name Lot#
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SEWAGE SYSTEtrI SPECIFICATIONS
Repair Lot Area , d �i cc.-c� Size of Tank °� -r
SFD Mobile Home Size of Pump Tank n,rr�
Business # ofBedrooms � NitrificationLine I�(�(; �X 3'
Max Depth Trenches_�� u
Permit Void after 60 months. Permit Void
Permits may be voided if site is altered o i:
Well and Septic Layout by
Comments:
S�'tt r�c Lf o�'J � � .
not in compliance with zoning regulations.
Date -- Installed by ��r ��SG,►'h-24=� Approved by
� I���- 12 -�r�
WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Siab
Public Re acement Air Vent
Site Approved Required Well Lo� _
Well Head Approved Well Tag
Grouting Approved I - - -
Comments:
This report is based in part on information provided the homeowner or hi Jher represcntative in the application submitted for this pennit The
enviromnental health specialist is not responsible for false or misleading information cocrtained in the application The environmental health specialist
is also not responsible for cencealed conditions on the property or for stat �cnents in this report that may have resulted from faLse or ausleading
statements provided to him in the application Neither Person Courrty nor the environmenta! health specialist wurants ihat the septic tank system will
cotRinue to function satisfactorily in the firture or that the water supply will remain potable: c:�amipro�pemvtsam O 1/95 rev. i.0
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date: %� � '
.0`wner: S T�� �n �G rc � SR# / 3 �_� '
Location/Directions: i 3 5 3 Qur h�.•-, �PQQ� ��
Subdivision Name: Lot #
Drilling Contractor: _/(�. • T� /� o�� � TTe
WELL CONSTRUC'I'ION
Distance from Nearest Property Line Distance from Source of
Pollution
Total_Dep.th: /ob' Ft. Yield: /S GPM _ Static Water Level 2S Ft.
Water Bearing Zones: Depth �o' t. F� Ft� Ft.
Casing: Depth: From O to�_Ft. Diameter: 6%y Inches
TYPE: Steel � Galvanized Steel �C'
If Steel, does owner approve: Y�s No
� Weight: � Thickness: . l fld� Height� Above Ground: l� Inches
Drive Shoe: Yes_ \� No . �
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Were Problems Encountered in Setting the Casing? Yes No
If "yes" give r�ason:
Grout: Type: Neat Sand/Cement Coricrete '
Annular. Space Width Inches
Water in Armular Space: Yes No
__ .. Method: Pumped . . _ . Pressure . . Roured x � - . . . _ = .
Depth: From to Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag lbs.
If mixtuie (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes I� No � ��
� 4 x 4 slab Yes�_ No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C�Ui�I'Y HEALTH DEPARTMENT.
`r����,�Cj --
Signature of Contractor Date