A24 25z
Person County l�eal�h Department �
Sewa e System Improvements Permit
Date: �`� ermit Void Aftgr 5 Y Permit #
Owner: n �i (ti% , s-Y SR# �
Location/Directionc� ,� � r #� �� �rG �' �� { .»�;v. �r � :—� � �
Subdivision ame: _J�. t Y t' �:� i" jsst% Lot #�
Lot Size: o� Uv ype of Dwelling:
Water Suppl . 'vate: Public: Community:
Bedrooms: �_ Garbage Disposal �
Basement Basement Fixwres
INFORMA � BY
'%- ' � ow or en uve �
$�1114'iT18i1: „ ...'� �/l&S. yt�"fr reP�
REPAIR: REEVALUATION:
Size of Septic Tank: � � s Size of Pump Tank: ----
Nitrification Line: ,��` 1 .i �� `
Depth of Stone: 12 inches
Max Depth of Trenches:
Alternadve System: Conv. Pump LPP Pump
Remarks: ,•. .� . „ -.-_--
-------------------------
Date Well Approved:
BY
Date Sewa ys
BY
Contractor.
Well should be 100 ft� from any sewer system
Sanitarian � . _ ., ,
Sewage System location, installarion, and protection must meet state and local
reguladons. Septic tank should be pumped out every 3 to 5 years and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and
nitrification line must be inspected and appioved by a member of the Person County
Health Departrnent before any portion of the installation is covered and put into use. If
the site pians or intended use change this pem►it is subject to revocation.
(G.S.130 A-335F)
L,ocation of sewagc disposal sewage system sketched on back. #``
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APPLICATION FOR:
�) Improvement Permit ( ) Subdivision
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Date Received:
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( ) Other �
1. Permit re uested by: - .�, � Home Phone �� -u (�
Address: , r! Business Phon -� 5��
2. Name and address of current owner: �,�G� u/.aY`�rs � �r- ��/ /� A Y�1a
3. Property Description: Lot size ��G , Dimensions:
Front " Left 3�� Right � 6 n Rear��
4. Tax map No. Township:C! U.tiN.a �Block No. Lot No.
5. Direc iops to property• State Road No & R�oad Name$ , etc.
nn� / 1_ .__ , n/r P / %L� A �L _ . %_ .�i!- _ C'/_ _ _L %�.Et �
6. Permit requested for: New Installation � Repaired
Additional Renovation re-using present system
7. Number of occupants of people served�--
8. Dimensions of Progosed Structure:� Width �� Depth z'�
9. What tyge (if any) additions, expansions, or�replacement is ani.icipated
te the structure or facility that this sewage disposal sys�em is intend
to serve?
.10. Type of water supply: Well �s no: If no, name source of water
supply: Are there any wells on adjoining
property? If so, identify location.
il.
Type of structure or facility: Proposed `�-Existing
Type of dwelling: House �ile Home Business
Type of business Number of Employees_
Number of Bedrboms Number of automatic appliances
Basement Number of basement fixtures
12. Clearly stake all corners of the property snd the corners of all propos
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 conten
of this application are true and represent the maximum facilities to be
placed on the property. I understand that if any changes are made without
approval from the Person County Health Department, the permit will be void
Any permit for a system is non-transferable without prior approval of the
Person County H�alth Department. Permits are valid for �10 months from. dat
of issue. �
SIGNED
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FACTORS - SITE EVALUATION AREA 1 AREA 2 AREA 3 AREA 4 i
1. SLOPE (%)
. SOIL TEXTURE (12-36 in.)
(Sandy, loamy, clayey,
Note 2:1 clay)
. SOIL STRUCTURE (12-36 in.
(Clayey soils) �
4. SOIL DEPTFI (in.)
S. RESTRICTIVE HORIZONS (in.
(Impervious Strata, rock)
6. SOIL DRAINAGE/GROUNDWATER
(External & Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
8. OTEiER (specify)
9. SITE CLASSIFICATION
(See below)
SOIL SERIES
S - Suitable
RECOI�QSENDATZONS / COMMENTS :
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PS - Provis
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Suitab
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U - Unsuitab
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SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies,
wet areas, fill.areas, wells, water bodies, slope patterns, etc.)