A24 120PERSON COUNTY HEALTH DEPARTMENT
SUBSURFACE WASTEWATER SYSTEM MONITORING REPORT
�� �2 ro 7 200 �b �� la �
Date of Inspection System Installation Date Type Tax Map Parcel #
��� �� �r s�� �� a�3�3
Property Address
Instructions: Check yes or no for appropriate items and explain inspace 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 ?
�nches of solids:
Septic tank filter cleaned ?
YES / NO
❑�❑
°a % o
❑ � ❑
EFFLUENT DOSING SYSTEM:
Required pumps present & functional ?
High water alarm operating properly ?
Floats, valves, etc. in good condition ?
Control panel & components in good
condition ?
Effluent free of excess solids ? ��
Inches of sblids(pump/dose tan ):�
Elapsed time readings ?
Counter readings 7
Drawdown rate: ^' � Q D/`'t
►� ■
■ ■
►:/ ■
.1 ■
■ ►!
DISPOSAL FIELD:
Evidence of effluent surfacing 7 ❑
Evidence of effluent ponding in trenches ?�
Surface water effectively diverted ?
Diversions/swales properly maintained 7 �
Vegetative cover maintained 7
Protected from tr�c/unauthorized uses 7
Distribution devices in good condition ?
Field free of settled or low azeas ?
REMARKS
� ��,�, � ,�x � a c�cPss; b �-e
aoro� r 5 �� �t. � ��� �'°�v�e �
d►-i ve .
� ���- q la�-, �ra-�- a�'6[e
�C 50►'Li� C� Wa S� �i /l�i ��.c2� �0 ?C
� aNl�S (iiit�C T� � r�l�lM� Ou.fi•
/
� S�,$,Q o,� I�loc,�� �-5 Se� over
�rq;�.-�e(cQ, �opS�''f— Q�pj�' �-°
� �tu�-�;� (�v���+�e�� �a►����ceS
are d.eP� �� �co �;� occ���.
PRESSURE DISTRIBUTION SYSTEM:
Turnups/cleanouts/valves/taps intact &
accessible ? ❑ � ❑ N� � �0 �5�,�(v� (��; .� � �•T
Pressure head properly adjusted ? ❑ / ❑�/�
COMPLIANCE:
Compliant
Non-compliant
Needs Maintenance
AU�i 1 IONAI, CGMM�ENTS:
f�:
■
■
-- _ �1.z2� . .� - .
, -- �_.,..�._,�,r, n .
• '• � � S-.54-0.3-.;�• / : , .
�j ` S'�9. �`'�� •.
.. ` � 8 � , G � � 9 _ V �a, �� .
. 7,. I 8,; . �. . . . °•�'
. I � � y !• ''I • . • .
5 . ,'
`� � .. . . .�'..� .�•
,�
,.
� , t� . ., 'r
� � y . � . .. �' . .
.�– p�0 r`�'�' / ' . . � �. . '�';,J.• • � , o
� ,� �,� •';.' . �• � .�,.', , -
� � �,�� . ; • . . . ,� . ' . . . f
�`1 � Z' • . • � . . '<, ' : j � • , • �' � .
:— , ; . ,
- O ' . • . .
� ' �ti
_ o ,y , � �
w �, ,� �� � . , .
� , w ' �^ p � (� • � ,,, �� c � (
� � � � � x }�� i. � � '' � �
� � C A O . .' � �
� x .� N . V � :
.� p ' .. , �j '
.
,, _.
�, . � _._ , �, • G � .
= � � , - i � :
1� � ^ . �
� �'.,' p' �' � . I ` '
o L �; . . . �
�a ; . � . .. . _
_. - ,�- '`, t�
. �. � . • . .�
� � � + . �,�. :� . �� � � � � . ..
� ,�`'� ,,y.c; . . . . . ,
I � �; . . . .
�� `� ' � �'.s, � . ., � . � .
`.�y y �� �,� " . � .
�' ' . �"'�B- �4-�4: ;y �. .
�• .��5 /E .
.
� bl � GK i.J �T'�i
DF
,/,,� ��e �
i.tl��Dn /
pa.�L val�c
/
()�oP � �
�
�I ��S ��ull i�s�c cf��! �-, �o.�c�
�'(u ��''1 U, S Y
S{a�an-�--�, a�ound ca�uf� O�
�' 1.� �!' cS � �¢�" (
�-: 5C � 1. � . ./
z n w� s .,/
Z w�r �
�
W
¢
z
.� 10���°� b �� G -z�-`�-�
�
� ...�� �q
�'��"'� t q� � APPLICATION FOR SERVICES
�- , :: ,;.
,; ;; , ;
,. ,
` ' ' . .Services Requested:
, :
�Imnrovements Permit (Established/Recorded Lot) _. Reinspection of Existing System (Loan Closing)
Imt�ovements Permit (Unrecorded Lot)
Permit (Mobile Home Replace)
Improvements Permit (Addition)
_. Bacteria
l. Permit requested by: .
Repair/Replace existing S
Permit for New Well
_ Replace Existing Well
_ Chemical I Petroleum I _ Pesticide
c System
7. Dimensions or Proposed Structure:
d- 'dth: ��
,�, � Depth: Sc7
ne Phone #: ��O- S 9?--� 3�/
iness Phone �:qlbrSc�3 ��v�9 0
Lead
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?
Name and a dress of_current owner: 9. Water s ply ty�pe:
�- private public ❑ community ❑ spring ❑
� Are any wells on adjoining property?Yes No �j.
.
If so, identify location:
Tax Map#:
Parcel#: _
. Lot size: � . O
�� / �+ 4�� A r�t
. Directions to property: State Road #L&,,.�/R—oad
'---- —�_ An.L7 GC/ _
Number of o��upants or people to be
10. Type of structure/facility: Proposed: I�xisting: Q'
Type of .dwelling:
House: �'Mobile Home: L� Business: ❑
Type of business:
Number of Employees: 3
Number of bedrooms: _
Garbage Disposal? Yes�o �i
Basement? Yes ❑ No f so, # of basement fixtures:
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 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 property 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 Depi., this application shall become void and all fees paid forfeited.
Signec��Owner o Authorized Agent
Permit Issued �
Permit Deni�d ❑
Plat Observed �/
Signature ��f���__�ll M�Date /-_��'�� ,�; , •
_
,; .
;; ..; FxCToxs-srreEvnt.unnorf ;; , ...;; N?�s;t n ni�A2 < nxEn3':. . . ,�+a
_ _. _ _ _:.
1. SLOPE ('b)
P �' //� d%O PS PS PS
v � U U U
2. SOIL TEXTIJRE (12-36 iN.) S � �— S S S
(SANDY, LOAMY. CLAYEY. NOTE 2:l CLAY) PS PS PS
U � � U ' U U
3. SOiL S7TtUCTURE (12-361N.) S S S S
(CLAYEY SOILS) PS PS PS
U S U U U
4. SOIL DEPIIi (IN.) S S S S
PS ' � � �/ PS PS PS
U U U
5, RES'IRIC77VEHORIZONS(IN.) S S S S
(IMPERVIOUS STRATA. ROCK) PS � � PS PS PS
U U U
6. SOIL DRAINAG&GROUNDWA7ER S S S
(EXIERNAL dc INTERNAL) PS � D PS PS PS
U U U
7. SOIL PERMEABILI7Y S S S
(PERCOLOATION RA7"E) PS y��, PS PS PS
U U U
8. AVAfLABIE SPACE S ! S S ` S
PS �/< PS PS PS
U � U U U
9. SITE CLASSiFICATION(SEE BELOW)
SO1L SERIES
S-SUITAIILE PS-PROVISIONALLYSUITA6LE 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.� C:WMIPRO�DOCS�APPSEC.SM FiNANCE.PC
_ �r.z�� • � - .
^ ..__..-,.._...._-._..1- , . � - ,
• '' � 5-.54-03-.;� � /i� � , _ '.
� G S. � 9. �``—`3 � _
.. } � S 8 _ � ,, �, v -�,��,.�
7.' � ,,�. . . E' � .
. o . 2 , �., . . � �
5'1 � . . �.
� � � .• �^r ' I f ,� l r , � ' .
�•� . �. �-�:,• � .
� 0 ,- . . \ . .�,
\ p �C�j , ;: . •� , . .� o
"�'�- ,�� p � � � . ,� , � ."C� .:. � � '
� �,,.o� : .: . . -� � . . � - . __
� . : -. , • ' ,.;; ,�.' . .,� r
�`• ` � • • . ;� . ,��•
.
O o , � , �� �,T �~ � ,
l.� � �' . . �
,�, �
• � � o � � . (,� . � --�.°Y'`� � ,.
� � C.7� �` ^ � � � ' . .. II_"
� A � ^x k� � � � ( � �,�'
j'h �h ' d� . . �•�
. r , A � � �4
P � . � J � �.
.Z ,, , . G � , x.._
i �., .� � � -- - , - ; _ i
f �i v � . ' �
-�'•: p. � � ♦
� G� c ' ^ ���► . � �
d i, r , ,
' _. -� . - ,�. � � � j � � .� ►► � , .. .__ _ .
� • � ��� i • �•�� .
; � � . .
, . .. �, . ,�
� � � �,;� . • ` � ' . � . ".
� � � . . . .
�l c(,, ' G� . .
, S.
! •� .
r� y. y � °''� � .
,%' N' 'q�- 3O-Sq� ;,y .
•. 1�s,� „
�
� �.. .
� .
- �_ � �
0
0
• • AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
'� � (Void sixty (60) months from date of issuance) �
DATE: � � IMPROVEMENT PERNIIT #: ,� I �
� TAX MAP #: PARCEL #: ��. C�
OWNER/OWNER'S REPRESENTATIVE: I�l; ��� G� vo v� S'�'e ��I�
LOCATION/ADDRESS:
S (Z-� 13 �`�—�> S t2.� � 3 � irM G � � �; i( (2d � •-�
,�, s G r� %.� �}` i n!v s
�
� l�" /p�� yo ' t,���
s � I.�t� �k �
�� !S C J � CP n � -�D � �1 I�.J � .,�f No w �, n j � �„ ' /1
S IVISION NAME: LOT #: �/`���
�7 � "���ivirf
SECTION OR BLOCK: �"��
AUTHORIZATION FOR
ISSUED BY:
AUTHORIZATION CONDITIONS
1. The Wastewater system construction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Permit #� The
construction and installation must also meet all applicable rules and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any alterations in site or soil conditions (including structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authorization and associated permits.
4. Conditions:
S�iP �,C S, / S� v�1 Y►'1 v,� � C'..r� vr S' �� f f �� G� �� V�' n� a n�
r� � �
5 t`�` v� `� ��l 1 C ��.,1,OY� � i m cs
� C <, 1 S-f7��-2 Ij Yl�-1� C� A
Person Requesting:
�
/�oJ-�
v
/� ��=e.
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: l a l� Il�IPROVEMENT PERNIIT #: � 9 ZID.s
TAX MAP #: PARCEL #: �S�
OWNER/OWNER'S REPRESENTATIVE: t� �! I �n� �c�f56✓�
LOCATION/ADDRESS:
� F � � �i�onl Kar � .
SUBDIVISION NAME:
SECTION OR BLOCK:
LOT #:
AU'THORIZATION FOR CONSTRUCTION ISSUED BY:
AUTT-iORIZATION
1. The Wastewater system construction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Permit #�315�0-� The
construction and installation must also meet all applicable n,iles and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any alterations in site or soil conditions (including structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authorization and associated permits.
4. Conditions:
�h�a� � c��� P�►�D�� �i�nG� � � � /�X• /�p���
; �► . �-� �•,��
� o so � I -�' 11,
Person Requesting:
-'.
,
.. ,.
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlV�RO`JEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map #� � Parcel #� �o� �
Zoning Township � V r'J �L �'► Gl � rv►
Owner/Contractor V .�- ��a ror, S•fec�ke.�- .Da�— %-- 3� � � �
Location/Address �(L-€� ( � 33 ,-i� Si� L�. � � -� g h � ��^� -s �b
/ � � _ _ . i i /� ' . i e . � � �' . iv I I 1 h �i %
Permits may`'be voided if
Well and Septic Layout by,
Comments: .
Date �p—f� ro ( Installed by
This report is based in part on information provided the hc�neowner or his/her
representative in the application submitted for this permit. The enviroiimental
health specialist is not responsible for false or misleading 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 County nor the environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
:�
,. .._, .� � • z 2 � • •
. ' �' � � S - .3 4 D�� �, ' �
� S. �. `j� /� � �.
.: .� $ � - � �
. -• � 8 , � . y- �� � 9. V � v .��� •
. 2 7, , l ,,• .. , . . � �, � o.�- �
S.'7 6 ' . � ., �, . ' . . �. ,� .� �,
�• .. . . . ; , W � � �
� . . ,� � �
� � ,.� � �-� .� � 4 .
O� •� `" � `�
M�- p` �� - r
� , � ... t � �
� � �• O �'S . .�• � � , .
. � ) � �. • ' . • I . • . C •
vr
�. ' � � � �.► f'
�•. � • , / ..
�
Y p ' • � c', ' � (� .
� —" �
a � •
(� Q C'n � ��' . ' - �� �y
1 �f� ' cy► r � o u� . C' �.S'o�� � �
V� \ � � , .
� � � � � � x � �'``'' �J� t,�
' cT1 �r, � � . � � � ;h
. .. . �
, � . X � , � � � _ '� _� ` � �-'�
.Z �a • _ od N N hJ �
` • y� i� . '
- n `��'- � �. �" _' �
I � ,�_t� �9 _ � , �, _=� .
� � A.'� ��°•a�' �
O ' ' �, ;- rts�,. � ' �`�� � = � � � �
�. � � • � � �� C �'tY. �p �.' �i � ``^�
. ^ '° 4 zc c � '�` '� � ti. tv �
�� O .. t , �
� . �. r �: � � � .
. , , �, �
� � 7� R ���j � . � � .
� � o � �l 1d .� . . Q .
s" � �o�� �� � ' ' • . ,
� GS� � A `�y .: ; •. � •
���� � � � .
+. . �y � i%.�-� = � --s `y'' . ' �/ " q� - � o _ �' . . �
oq,o s�,� � y, �, ., 4: ;,y .
� o�. � . , .1 � s i <- �, "
.... _ . . .. _.
�r.����;. �.. }'."'.�.•..• .. . .•i?h_ . � .:{.`.1 L. 1 � . . " ..._ .. . _`t . . . � � n � � �
H
�
� 1'I:li:i(1I�! l:Ufl��17')'
���--� J �. J , �:lVV.l.I(UNP;::N�i�r�i. iu;nt.�r.ti
5
�._ ir�•:i.i. i.c�c; �
Da te: �_ - --1,5,. �-� � �
Ownez-:
��L �e r .
Loca[ion/Dirc tions: _�{`fs�6;�`�w� ......_._._ 5�2�#�
�
�
,
�t.l�;!�visio,�i N.in�,c: _._� ........ ......_.__-- � -
,Uri11in 7 Con .."
b cz-acco�: ---�U�-ns..__.y�� .��. �..r.,.../.�� � ......... ......--.__ Lot �� o �
Disc:u�cc lxo»� Nc•u�cst a 1'�I l.t .c_:CjNti_I_.I�11CCf'I(�jjV. ..---�_
� 1 ro��crly [_,iu�:.. '
Pollution___:_���1�, �-�� �J�.__ .D�,,�.ir�cc ,Crom Spurce o,f '
Tota1 Dcpth; � .
Ft. �'icicl:-.--.��._.. .y C;�'M Stalic Wa[er L.evel
WatcrBearing rGones: U�
C . 'ptl� _... .. ' ..._ � � � �
asin�: ,Dep[h: From � .�'.Q 1 ►. ......_--- .-..�'(. _
�'YPE: Sicel d-.__...�i�._.�../-.-..__�'�. llianic�ci• �'[6.—._�[.
—'---- G.ilv:uii�c;cl Slccl �-- Znches
X.f Stccl, docs own� ��prov�:: �'G:: _____. . .
'Weig1it:'___ /�'l1lic�ics ---- Nc�____ .
J.
Drive S11oc: Xcs__ _� Nc� `����-���ght:`��OVC Ground:�,�nches
Werc Problci + - `-.-.. � .
Ils E�icotziltc:rccl �l�l .�ctlint; tlic C:IJ17lf�'1 �`cs �� —'---
�1� .,ycs" j�ive: rc.ison:
-_____ No �:
Grout: �ypc: Ncat --..___.__...._._._--..__ _.ti�...___._ —�
.� :! 11 C.��(.; �:111 C!7 [ L_.
�u��:�s���� wz��n__ 3 --- - --_____Coricrete • . . ::��,
wZ[CI" � ^ . _...._ ._,.�j11C11C$ .r�..
11� .C�.Ill�tl�.ir SJ�:1C:1:: ��('.� •
Mctliod: � . .. . ...---��-- N� `� .
X w-i1 x:c t , •_.__.
I � �------
, . —�-._... ._ 1 r'c:::::ut1:
S�cpc1�: I-xom ... .1'uurc:cl �-- :. .
�--- --� . . �, � � � �_.._... . i : L.. __�_--� .
Matez-ials Uscd: No.,��aLs,l'c�l� -�.._ � .
ZFmi�;[11I"C �S1I]CI, �r;lvc:l, c��t.�i�.�„!`u�d Cc�ncnt_.... ____ W�i ►
Z,U �� ;, ) IZ.�tic�:_____ �— 1�1t o.f.1•ba� 9 c�:• lbs
l:itcs: �'cs ✓ -. co —���.— ,.,�
� Nc' - . .
� 1 � �� :,lab a'cs___ ✓__ N�� _. .. ' � . . :. ,
.._ . _ _.. .._ . _._
I---.--______----..__._....._ ....OI� I l ,( .1 i'VCr 1,.C)C;__
�� �>> .
Fram 7-----° � _ _...�__�-_....-... I�c7r,n<�ti �� `` �
� �— � ----- ----�!�1�0 �,J �-% `�.`.��[i�n
-•-.__�[1 ro
I- --. .. _�•!^ t_c.. � -�2�_�,
_�_�_�--,�3-
--._.��2e.YL... . (.P' r�a-,� .
Z �i E _`_``---_.. _.__. ..... . .._.___� .._ �_ . :; ;:; �.
. . .Z,� REB X CE�ZT�Fa` �f'FIt1'�, .�.� I L �.13 () V 1; .[N1= ` . . .• ��
� :4 y1�
S WE�.L W!1S C UIZM�1'1'!ON ZS CORRE ...,...�
ONS 1'I: UC1',�1) l tv ��,�CO1�,U �' AND T.H%';
.��'�RT�-I fiy.T�-I� PEIZSON (:nl1.N �'1' FI1;11t..`I'(-I '�CL W�TI-I 1ZEGULA"�ONS��S�,�I',
.. .. Z�LPni:TMCN�1�. � .,,,,��;
.. . �✓� .. ���_.�--
.Si�;n.�(urc ��f� Conr�.�,:(c,r _
� :�.:
- 6- �u v'`s�y;
� Datc '��"'
�: �