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Cunninyham
Oct. ,1983
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Paul L. 8ai{ey, R
Site Evaluation Application
Fee Collected YES � NO
Date:
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�05-�
�✓ 1� APPLICATION FOR IMPROVEMENTS PERHIT
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l. Permit requested by:
2.
Address : (�,
Home Phone ��:
owner/pruspective owner: �
I / agent �
�C �A (� E. ! (� � N � �.� � -
Business Phone ��:
dress�a�f cu�rent owner:
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3. Property Description: Lot size: l DQ ,� I a�
r �
4. Tax map ��: Township: U N c
Subdivision Name: � •- Lot ��:
5. Dir ctio to propert : State Road �� & Ro�d Na es, etc.
��� �'�� �i=� � c. r� r� 1� �'`#;— �� �, r� � �1' , :
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:
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? �
10. Water supply private? public?
Other source? (Specify):
Are there any wells on adjoining property?
11, Type of structure or facility:
Type of dwelling: House:
Type of business:
Number of bedrooms:
Basement? Yes No
community? spring?
If so, identify location:
Proposed: Existing:
Mobile Home: Business:
Number of Employees:
Garbage Disposal? 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 iss e. Permission is hereby granted to
enter the property for the evaluation. G.S. 13 A-335(F) _
t � I - .
gned Owner or Authorizen Agent
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Permit Issued
Permit Denied
Plat Observed
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l�ACTORS - SITE EVALUATION AREA 1 AREA 2 ARF.A 3 AREA 4
1. SLOPE �X)
2. SOIL TEXTURE (i2-36 i.n.)
(SandS, loamy, clayey,
Note 2:1 clay)
3.. SOIL STRUCTLTRE (12-36 in.
(Clayey soils)
4• SOIL DEPTH (in.)
,5. RESTRICTIVE HORIZONS (in.
�Iu�ervious Strata, rock)
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SOIL DRAIIIAGE/GROUNDWATER
(F�cternal & Internal)
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SOIL PERMFABILITY
(Percolation Rate)
$. OTHER (specify)
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g. SITE CLASSIFICATION
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECOt�4fENDATIONS / COI�fIIITS :
S1TE CLASSIFICATION DLAGRAM (Include: Soil areas, property lines. roads, streams, gulZies,
Wet areas, fill areas, Wells. water bodies, slope patterns, etc.)
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^l�J�M CO�N�
Rebecca L. Hester.
H.N., M.P.H.
ftEAITM OIi�EC70R
�Ezson �oclr_Ey �£a.�E�i. 1���azf�r_�r_i
�29 csouti c,i'�o:9nr_ cs!ttc!
cJ\ �r(�u:o, t��o:l� ea:oiira 2 75 73
`�cfthf�„�e �q�9J 597-zzoq
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TO WHOM IT MAY CONCERN: �
The . � e%o� �� i S Caw�r S/D tract of land, tax map l��y— �r'�` �
was found to be unsuitable for a ground absorption sewage disposal
syster� that can be appr.oved by the local health departnent.-
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