A24 112z
� �;;�r�on County Health Department �
Sewage System Improvements Pe� Tm1, it
::�.This Permit Void After 5 Years Permit #—_ ���;��
Owner:
SR#
Subdivision Nar�: U � "' � Lot # � _
Lot Size: V t e Type of Dwelling:
Water Supply: Private: �_ Public: Community:
Bedrooms: � Garbage Disposal '
` �asement ��— Basement ' e
INFORMATION CER'I'IFIED BY -� " �
Environmental Health Specialist: '"'"�` � ` �'tahVe �
REPAIR: � • REEYALUATIO : -
Size of Septic Tank: %�� gallons Size of Pump Tank: �
Nitrif'ication Line: � ��3
of Swne: 12 inche
pth of Trenches: ��
temadve System: Conv. LPP Pump �
Remarks: gy�,– ,��
-------------------------
Date Well Approved: /-�U -�7 3 Well should be 100 fG from any sewer system
By ' � Environmental Health Specialist
Date S age te Approv • ���_-��
gy Environmental Health Specialist
CATE OF COMPLETION :
Contractor
Sewage System location, installation, and protection must meet state and Iceal
reguladons. Septic tank 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 Peison County
Health Depaztment before any portion of the installation is covered and put into use. If
the site pians or intended use change this pernut is subject to revocation.
(G.S. 130 A-335F)
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
� ��erson County Health Departm�nt � �
Well Permit � �
9ZThis Permit Void After 3 Years
Owner: j �n hv�
Lacadon/Direcdons:
Subdivision Name: ,
Drilling Contractor.
�
l�iCcYv�7 J�. % T
� SR# _ !�1
WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Polludon
Total Depth: FG Yield: 2- GPM Static Water Level Ft
Water Bearing Zones: Dep� Fs.� FG F� �,Ft.
Casing: Depth: From to Ft Diameter _��� Inches
T'YPE: Steel Galvanized Steel �
If Steel, does owner approve: � No
Weight: Thiclrness: Height Above Ground: Inches
Drive Shce: Yes No
Were Problems Encountered in Setting the Casing? Yes Nq
If "yes" give reason: i �• ,
Grou� Type: Neat San ement , Concrete
Annular Space Width �� Inches i. .
Water in Armular Space: Yes No .
Method: P�mped Pr�s�e Poured �
Depth: From _� tovJ FG
Materials Used No. Bags Pordand Cement Weight of 1 bag
lbs.
If m'vcture (sand, gravel�¢utiings) - Rado: to
ID Plates: Yes No
4 x 4 slab Yes �— No
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I HEREBY CER'TIFY THAT THE ABOVE WFORMATION IS CORRECT AND THAT �
'THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET ;�
PORTH BY THE PERSON COUNTY H�T EP �'� 6� 43 �
f�lh
\•�U
Si o n ac Date
� �I2�I�Z
Sanitarians Signature Date Issued
Sanitarian's Signature Date Completed
Sketch well locadon on reverse side.
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The District Health Deportment
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT No.
J Date � � -:r� � _ ;r ti
[—l��/j/..� "i .1��i1 YYPn �• .
Owner:
Location: n •
J .'r� ;,'.�, �:`;'.��, t" '1.' -'" >r`i_f�-r"li{:�,_;;F
'r i J ,_..... -�T' t' 1: i ni f'l±'~" .� ., 1/-', .!/ � U
1
Contractor:
Water Supplp: Private Public
Sewage Disposal Facilities: No. bedrooms -� Dishwasher, Disposal,
washing machine, other automatSc appliances .�.' ��'1-� ��,L%��
i��711 � : ji' �: :;,;: ' � �' .
Size of tank: �—� line:
�
'.1 �
Other disposal fac ity: � � � ��� � ° /'`� ''f `� ��"'i�
� uv �r. ��I,�:��
Water supply and sewagc.r �dispos�
protection must meet state and 1 c
Septic tank should be pumped out`e`
tained by owner in such a mann r as
Septic tank and nitrification li
PROVED BY A MBER OF TH
STAFF BEFOR ANY TION
ERED AND P INTO USE.
Date aF
Well:_
Sewage
By:-
ce:lifca:e of
and
e 3 to 5�ye� an3 shall be main-
t�''a public health hazard.
i T BE INSPECTED AND AP-
IS ICT HEALTH DEPARTIVIENT
F T E INS LLATION IS COV-
\ /� ,
/1 j �� � �f r"
�
Sign¢ ,��'t � W�if/"�' -ti%"
Sanitarian
�,:�� 1
Counter-��,� c'�„(1��� /
aigned �,.
(Own is representati e)
Date Approved: By: —
Sanitarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
sup� lies, 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.
(1> (Z)
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Site Evaluation Application
Date: ( (7' o�� - cl �
�
�`ee Collected YES ✓ NO
0
t a5'� a�
,+ �l a. �c e"� �� p��^� l��'� / APPLICATION FOR IHPROVEMENTS PERHIT
a�c .� �� 1 �4� p � �,�
1. Permit requested by: owner prospective owner:
., _ ,. _ ., agent:
Address: p1'1'.
Home Phone ��:
I� � I�1 � X�00'�O N C o�
q � • Business Phone ��:
2. Name and address of current owner:
3. Property Description: Lot size: �� 0 S 3
�a� ii a
4. Tax map ��: � Township: ��' c.h�
Subdivision Name: �0� S. Cc�r��X Lot ��:
3
5. Directions to property: State Road �� & Road Names, etc.
01 �. Mc G h e� S r�� � I,-u r�-4� C w s s �.; 1 rv ��ci. -�c��1� 1� r� d c, Q. L ��
S11�re 0ri � c�rosc �l,-o-v.�a\ b r; d c�� �r ��� a� 1s� �i;�i}-l.� C,�vsc
r.rnc� �a�� C'�.� o c(DSi Ov� �e�� 0.� �A� � �i1C1Z . �e�-�-. c.� 1$��
- 6. Permit requested for: New Installation: � Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served: oi
8. Dimensions of Proposed Structure: Width: Depth:
m
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?
H
w
x
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w
10. Water supply private? public? community? spring? .,�
�
Other source? (Specify): �
Are there any wells on adjoining property? ir1� 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• 3 Garbage Disposal? Yes No �
Basement? Yes � No If so, number of basement fixtures: 3
sink,sl.A.,.�.Y� ��.rr-�a.�-
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-335(F)
��J2��� � .
,.
Signed Own r or Authorized Agent
/_ � .�{, ,'s
Permit Issued v I �'1 �
Permit Denied
Plat Observed 1/ '
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rACTORS - SITE EVALQATION AREA 1 AREA 2 ARF,A 3 AREA 4
S S S S
1. S�OP�X) � �� �� � PS � PS
'/�t• � .
� �+ U {,1
2. SOIL TEXTURE (12-36 in.) g S. -
�Sanc�, loamy, �Iayey, '� ��� PS P PS PS
Note 2:1 clay) ` U
3 SOIL STRUCT[JRE <12-36 i.n. ) S S
(Clayey soils) � �IRyz PS PS� PS PS
' sa Wc��cs
� r i-� r�. L__ �i S
4• SOZL DEPTH (in.)
5. RESTRICTIVE HORIZONS (in.
(Impervious Strata. rock)
6. SOIL DRAINAGE/GROUNDWATER
(F�cteraal-� Internal)
c
7. SOIL PERMEABILITY
(Percolation Rate)
$. OTHER (specify)
�
U
S
PS
U
r 6 $
�,7 �,�(o �, ps� �CJ `=,3�'�
S
PS
U
S
S
PS
U
$
P
S
P
S
PS
u
U
$
�''- 3�" ps
U
S
PS
U
S
PS '
U
PS
U
S
PS
u
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9. SITE CLASSZFICATION � � , .
(See below)
SOIL SERIES
- S- Suitable PS - Provisionally Suitable U- Unsuitable
RECOt�RSENDATIONS /COtRiErITS :
S�TE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies,
c�et areas, fill areas, �rells, water bodies, slope patterns, etc.)