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A24 19� � � 0 �� 17 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION INIPROVEMENT PERNIIT Tax Map # �%- � `� Parcel # - % oZ 1►` / � Zoning Township n n��n o�M Owner/Contractor � P � � l Date a$ S Location/Address Sh �P -� r s S.R.# Subdivision Name Lot# As Installed Layout -�� Per►�.�+ wc;�� �td a1lo� p,dU �'i-►� n o-F G rea�--t �car` � Lar�.�e c� ��(-h Na e l�r.�►,�� �-o t � eX�s�+nc�, S4Si"QM 4 � e d � �asr � � r 0 c�- — -- --�.. � � i i � � !�t,�i I ' � SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area / A r �� Size of Tank ��c�5�i nc� SFD Mobile Home Size of Pump Tank Business # of Bedrooms Nitrification Line Fx%��ir� �� n � e� m.�- r p Max Depth Trenches Pernut Void after 60 months. Permit Void i ot in compliance with zoning regulations. Permits may be voided if site is alte;ed or int� ended u�, a ed. Well and Septic Layout by f� r�(�� � Comments: Date Installed by Indi ' ual Semi-Public lic Replacem Site Appro d Well d Approved Gr ing Approved omments: Date Inst� by_ Approved by 'ent _ ired Well Well Tag This report is based in part on information provided the homeowner or his/her representativ�the application sub ' ed for this pemut The environmental health specialist is not responsible for false or misleading WoRnation contained in the applicatio The environmental health specialist is also not responsible for concealed conditions on the property or for statements in Uus repoR that may have resulted from false or misleading statements provided to him in the application Neither Peison County nor the environmental health specialist warrants ihat the septic tank system will continue to function satisfactorily in the future or that the water supply wilt remain potable. c:�amipro�permitsam Ol/95 rev.1.0 ORIGINAL , _. . ��.. . y. M1.�..�sm,� ^.e^e^h .\ ey.,. 1 ] P _ �: k:t ' � � � � : . ' � �:t. � . I,� . � � � � � ��son Co.unty Health� �D���e������partme�n� y� �% �� �,..�. -_:�..�.1�T�11��i�" - ___ _- --�-� �ate '���Thr Pe 't Void After<5 Years , " �"F' ; � ` � � ` `� � � r � ".� G :'z Owner� ... . -: G��c?h _�i�'��,.5'D N SR# �.�3%�_ b ' " _ ' `. ��� Locat��rr/Duecaons. -� �; L v� Q. c�' �' _ � N - . ., S � / ,.'Q �, s�d � � _ ' :.i _' � � �. Subdivisio�Tame. ` -,_ �, � � Dn1Lng.Contractor: , � _�b # � " � ` . � WELL C NSTRUCITON p, p� �; Distancr: from Nearest Property Line Distance from Source of ' A•' �� ' Pollut�on ' . ,�v �S ��- , . - � y �F �.� � ✓ y Total Dr�th:� FG Yield: --� PM ' Static Water I:evel��Ft o�: p;� WateyrBearing nes• Deptli FG�FG�_Ft �t, � �, �, C a s i n g. D e p t h: F i i o m�_-�t Diameter: 6:i 1n'ches . T7fPE: Steel Galvaruzed Steel `�`"� b � S, � n`� � - ' If Steel, does owner approve: Ye's No � � � a� �� Wei ht ' . �. � a�. 8�,�. Thickness Fri�ieight Above Groimd:_;,[_,7._ Inches ` `D• �' �� O c� C. DriveShoe: Yes � No " � ' � ' � � O Were P ro b lems Encountered, in Setting the Casing? yes o � ' �"' � ' � � y . If "yes" give reason• , !, • � � y o . G�nut: -Type: Neat Sand/Cement �" Concrete ' ' Annular Space Width_ . :S Inches . �, ` � �' �• Water in Armular Space: Yes � No � m� oa � .. Method: Pumped Pressure Poured c.� . � �~, � � O Depth: From D to�v g�, '; — � o� . Materials Used: No. Bags PorCland Cemen t�_ W�p*� . g��lbs. � �, � �� • I f m' i x t u r e s an d, f 1 b a .. , ( g r a v e l, c u t t i ngs) - Ra t io•_�,_ �� i � 0 G } ID Plates: Yes L� No �-- ►ti I i ��� ,� � 4 z 4 slab Yes�^No - . � I ' n' a� a i � . DRILLING LOG . , D�� � � : ��� � , � � � � i From To oanadon Descri don �� � . i �.. P' �--' I � � C � (. _ I • � y � � ' ' � ' ' � o. � , � � - c� � � �o , LHE1tEBY CERTIFY THAT THE ABOVE INFOR141ATION IS CORRECT AND THAT � ; ' �' � 0 THIS WELL WAS CONSTRUCTED IN ACCORDANCE WiTH REGULATiONS SET � FORTH HY THE PERSON COUN�'Y HEpL,T EEARTMENT. � �. � . �:" � cu �. - . - . .. ...:. . n v, . �� ; : .� r, :' .. `Si8 ctor - Date•. �! _. _ � �. - f .. .. : . , . G�7'yY � i , � _ �� �tarian's Sigria e. Date Issued. . I � � _ � t� , �.'d - Sanitarian's Si nature � C• 8 Date Completed � , . . ' . . ' � y �. Sketclt well location on reverse side. � �n . I . .- � � � ._. . � --- ---- ` --- _ . . ---� d � � • F.� _�" - _....I. . � _. . .. .. _ - ' � I he District� 1-lealfh Depar�men� `. ; .. �._. _.__ _ . _.:_ _ _ , . � Oraage, Person, Caswell, Chatham. Lee Couaties ' , _ .. . • i - - SE�PTIC TANK PERMIT � � � '� , Date ��� `� � � ; �!'�f�r ' � ��'* .,�- . Name of owner: —. 4� :[' l�� i1- -.•-� �C�' �����,�a�•� Name of contractor: ' -��� � Address and Dire 11 ions �, L's=—�' ����►-rv I UV i l� ! Person or firm doing installation: - ` .Ad<tress � ( No. of persons to be served Be rooih� 1,Z, �,_ 4 A3ciitional appliances to be used: Disposal, dishwasher, washing mar.hine � -- Recornmended• Septic tank_� r� Nib.tification line: ����� Abuve recommendation� based on information received. and observed soil condition. Septic tank and nitrification li�e mus3 be inspected and approved by a�meml�er of 3ke District Health Deparlmeat staff before any portion of'rthe installation is covered. � Date Approved:.� -q..� • Signe� .. ; . . Sanitarian By• '. ! . - .. O. David Garvin, M:D., �M.P.H. � District Health Officer Countersigned. � ' (Over) ' ! � � �� a'�� ,� 3 0 �,��. �e�e� Improvements Permit (Established/Recorded Lot) I_ Reinspection of Existing System (Loan Closing) Improvements Pernut (Unrecorded Lot) Improvements Permit (Mobile Home Replace) Improvements Permit (Addition) � O ►-.] Bacteria 1. Permit requested by: owner/prospective own� Ar1rlrPcc� ( � � � � a � � a _ Chemical "l Phone #: Sq � - 34v a :ss Phone #: Q t b-�l3 z� Lo ��\ Name and addre s of current owner: l�rS�ti-- '� � ��i �n�z� � Repair/Replace existing Septic System Permit for New Well _ Replace Existing Well _ Petroleum � _ Pesticide � _ Lead 7. Dimensions or Proposed Structure: Width: � b � Depth: o� � 3 8. What type (if any, additions, expansions, or replacement is anticipated to the structure or facility th�t this se`kwage disposaltsy�e(m is i� ed to serve? . o, � „�. � .�,�.,. Property Description: Lot size: i C�.U�-e Tax Map#: – 2-`% Parcel#: �7 � �" 1 �l Townshi� �1���� ►r��iyYt rx— . Directions to property: State Road #& Road fames, etc. C Cse1��--`1Y� ,-Qsz �:�- + � ' Q� � �� � 'L Carat si� r . Number of occupants or people to be served: � 9. Water supply ty pe: private � public ❑ community ❑ spring ❑ �/ Are any wells on adjoining property?Yes ❑ No L�1 If so, identify location: 10. Type of structure/facility: Proposed: ❑Existing: ❑ Type of dwe tng: House: Mobile Home: ❑ Business: ❑ � Type of business: Number of Employees: Number of bedrooms: � Garbage Disposal? Yes ❑ No Q� Basement? Yes ❑ No �If so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the PersOtl 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 Dept., this appli�t�or� all become void and all fees paid forfeited. Z `� Signed Owy%�or Authorized Agent Permit Issued ❑ Signature Permit Denied ❑ Plat Observed ❑ Date � � FACTORS-S7?E EVALUA770N AREA 1 AREA 2:: ,4REA 3 AREA d::: _... __ 1. SLOPE ( k) S S S S PS PS PS PS U U U U 2. SOII, TEXTURE (12-36 [N.) S S S S (SANDY, LOAMY, CLAYEY. NOiE 2:1 CLAI� PS PS PS PS U U U U 3. SOIL STRUCIURE (12-36 [N.) S S S S (CLAYEY SOILS) PS PS PS PS U U U U 4. SOIL DEPTH (IN.) S S S S PS PS PS PS U U U U i, RESTRICTIVE HORIZONS (IN.) S S S S (IMPERVIOUS STRATA. ROCK) PS PS PS PS U U U U 6. SOILDRAINAGFIGROtJNDWATER S S S S (EX7ERNAL & Q�T'ERNAL) PS PS PS PS U U U U 7. SOII. PERMEABILITY S S S S (PERCOLOA770N RATE) PS PS PS PS U U U U 8. AVAII,ABLE SPACE S S S S PS PS PS PS U U U U 9. SITECLASSIFICATION(SEEBELOW) SOIL SERiES SSU[iABLE PS-PROYISIONALLY SUITABLE U-UNSUI'CABLE 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�DOCSIAPPSEC.SMFINANCE.PC � �' ` � N �, �' � � ' , , � � � N . � �1, � N . . l� ,� ,. N � c� �w � � _ , � O , , , , � i � Q � ' � � � /, � „ . �, . .� � � �1 .. .� �il'� il i . I � yi �. � ,�1, i � � � � .. , , r . . 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