A24 113��a�-les �- SqN� Dees �
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�PP _ on County Health Department �
e S stem Im rovements Pe mi
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Date: �Z.This Permit Void After 5 Years Permit # ,�,_
�nez,�� ; � �—���i—'i��-���� T�. SR# _1�LG� �
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Name:
Lot #
Lot Size: � Type of Dwelling: l�
Water Supply: Private: ' Public: Community: 1
Bedrooms: ,�_ Garbage Disposal
Basement Basement Fixtures
INFORMATI D BY
Sanitarian: �i� ,?'w�er L��'tad�e
REPAIR: REEVALUATION: � �
------ ------ �
Size of Septic Tank: �� Sallons Size of Pump Tank:
Nitriiication Line: � � �
- �_ 't
De of Stone: 12 inches "
pth of Trenches:---- �v
temative System: Conv. Pum ! �
Remar . �
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_���� a�w►s �ha.,eL'a� vb-e .S c� 5F
P Q%� L t/� 1/i �p LI/ p„
Date Well Ap v���.�j��Well should be 100 ft fi
BY S�� fl Y� ,�r
Date Se e s roved• -
pr 0 �� �n,�
s�Q�•
m any sewer $ystem
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B1' $8(11[8T13I1 �-f1
CERTIFICATE OF COMPLETION ,,,,3
Contractor. �,�� j�.,,w; ,S �
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Sewage System location, installation, and protection must meet state and local �
reguladons. Septic tank should be pumped out every 3 to 5 years and shall be maintained
by owner in such menner as not to create a public health hazard. Septic tank and �
nitrification line must be inspected and approved by a member of the Person Counry �
Health Department before any portion of the installation is covered ar►d put into use. If �
the site plans or intended use change this pemiit is subject to revocation. ,
(G.S. 130 A-335F)
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L,ocation of sewage disposal sewage system sketched on back. �
�ti,,t t h<�QQ,��� (OVER�, --¢- ��`�=��ca "` '/ ,��.
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� Person County Health Department
Well Permit
Date:!-� is Permit Void After 5 Years n
Owner. G(� n v� jg� ��a., o!/P P s' � SR#
Location/D'uections:
„ 1�."v,i /cY _ nns _ S liY/�✓ y`
Sa'$division Name:
Drilling Contractor:
Lot #
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Distance from Nearest Properry Line_�s n I t<�r Distance from Source of
Pollution�t � d �
Total Depth: F� Yield: GPM Static Water Level_L�FG
Water•Bearing nes: Depth Ft. FG - FG FG
Casing: Depth: From � to�_Ft. Diameter: �' Inches
TYPE: Steel Galvaruzed Steel ✓�
If Steel, does owner approve: Yes No
WeighG_�Thickness: Height Above Ground: ,/?.-�inches
Drive Shoe: Yes ✓No
Were Problems Encountered in Setting the Casing? Yes No -
If "yes" give reason:
Grout: Type: Neat Sand/Cement '✓� Concrete
Annular Space Width 3 Inches
Water in Armular Space: Yes No v
Method: Pumped Pressure Poured �/
Depth: From_� co 1� Ft
Materials Used: No. Bags Portland Cement� Weight of 1 bag 'l�Y lbs.
If mixture (sand, gravel, cuttings) - Rapo: 'a— to �
ID Plates: Yes � No
4 x 4 slab Yes�—No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE W1TH REGULATIONS SET
FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. '
of
Sketch well location on reverse side.
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Date Completed
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NOTE: Make sketch't�in" stallati��owing lot si e and shape, location of house,septic tanks°`� ��irvies, water
supplies, etc. Note special problems existing on lo� Write in measurements in o�"der that installap�ri� may be
located at later date. Note location of water supplies on adjacent lots.
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Sit� �valuation Application Date: 2� __ / Z
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Fee Collected YES ,p NO
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: ,�� �� APPLICATION FOR IMPROVEMENTS PIItHIT
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1. Permit requested by:
Address: � � Z
Home Phone ��: 4/g
owner/prospective owner: _
� agent:
I.J ..�...�e.,.,.p�, � . �..�--�
. 79 /��� �a. Busi ess Phone
2. Name and address of current owner:
S�'`--�—
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3. Property Description: Lot size: ,�% ��� ��
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4. Tax map ��: /� �- � ownship : �,y�-�--�
Subdivision Name: �¢�
�— Lot ��:
S. Directions to prope�ty•, State Road �� & Road Names, etc.
Na-�?' -�- ✓ �Q. /�-
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6. Permit requested for: New Installation: '� Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served: �
8. Dimensions of Proposed Structure: Width:
Depth:
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9. What type (if any) additions, expansions, or replacement is anticipated to the struc-
ture or facility that this sewa disposal system is intended to serve?
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10. Water supply private? ►�'
Other source? (Specify):
Are there any wells on adjo:
11,
public? community? spring?
ng property?
If so, identify location:
_
, �� ,
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-335(F) �
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Sig e Owner or Auth rize Agent
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Permit Issued
Permit Denied
Plat Observed _�
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rACTORS — SITE EVALUATION AREA 1 AREA 2 �g� 3 .��
1. SLOPE (X)
2. S�IL TEXTURE (12-36 in
(Sands, Ioamy, clayey,
Note 2:1 clay)
?.. SOIL STRUCTiTRE (12-36
(Ciayey soils)
4 • SOIL DEPTH (i.n. )
S
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in•) S
5. RESTRICTIVE HORIZONS (in.
(Impervious Strata, rock)
. SOIL DRAI2IAGE/GROUNDWATER
(F�cternal & Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
$. OTHER (specify)
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9. SITE CLASSIFICATION
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECOt�QiENDATIONS / COrRiErITS :
SL�TE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies,
Wet areas, fill areas, wells. water bodies, slope patrerns, etc.)
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