A25 165Person County Hea�lth Department
� Sewage System improvements Permit
Date: ' "' This Permit Void After 5 Years Permit #�y �31 S^
Owner: ' SR#
Location/D'uections: % _ ' _ � - .`
Subdivision Name: Lot #'
Lot Size: �Gr�',��e. Type of Dwelling: �/�'1 �
Water Supply: Private: —� P�blic: Community:
Bedrooms:��— Garbage Disposal
Basement Basement Fixtures �
INFORMATION CERTIFIED BY ct.s�- _ - r/� ,
Environmental Health Specialist: wner or r��raa�e '
REPAIR: REEVALUATIO :
Size of Septic Tank: �� gallons Size of Pump Tank:
Nitrification Line: ��/7r1 � � � �
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remazks: , .�� „ � � /� ,
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Date Well Approved:
BY
BY_ar v nga�y��mf tpprov •
Contractor.
Well should be 100 f� from any sewer system
Environmental Health Specialist
. Environmental Health Specialist
TE OF COMPLETION
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Sewage System location, installation, and protection must meet state and local
regulations. Septic tank should be pumped out every 3 to 5 yeazs 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 approved by a member of the Person Counry
Health Department before any portion of the installation is covered and put inro use. If
the site plans or intended use change this pemtit is subject to revocation.
(G.S. 130 A-335F)
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
� NO�TE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
•
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations m1y be located
, at later date. Note location of water supplies on adjacent lots.
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Person County
� W�II
� �.r�3 This Permit Void A
Owner. � i n
Locadon/Direcdons:.
Health Department
Permit
'ter 3 Years
n/e,,�co-►� 1 sR# /�
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Subdivision Name: Let #
Drilling Contractor. JLBr2S 6
WELL CONSTRUCi'ION
Distance from Nearest Property Line I�T Distance from Source of
Polludon o ' o uS
Total Depth: � Ft Yield: �GPM Stadc Water Level �Ft.
Wetet Bearing Zones: Depth Ft Ft. Ft. t.
Casing: Depth: From � toa�� FG Diameter: � L Inches
TYPE: Steel Galvanized Steel `�—%--
If Steel, oes owner appmve: Yes No
Weight: Thiclrness: �L.�� Height Above Ground: _�yIr►ches
Drive Shce: Yes `�� No
Were Problems Encountered in Setting the Casing? Yes No�_
If "yes" give reason:
Grout Type: Neat Sand/Cement '-�Concrete
Annular Space Width � Inches
Water in Armular Space: Yes No �- ''�
Method: Pumped Pressure Poured�G �e
Depth: From Q to � FG
Materials Used: No. Bags Prntland Cement �_ Weight of 1 bag ,�
�� lbs. �
If mixture (sand. gravel, cuttings) - Ratio: � to �_
ID Plates: Yes `-'� No
4 x 4 slab Yes �- No
De th
From To Formadon Descri tion
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I HEREBY CER'I'IFY THAT THE ABOVE INFORMATION IS CORREGT AND THAT �
'THIS WELL WAS CONSTRUCTED IN ACCORDANCE W1TH REGULATIONS SET ,T
FORTH BY THE PERSON COUNTY HFALTH DEPARTMENT. �
Sketch well Iceadon on reverse side.
nL�'��lrl%lL _���/
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/�i., �i� � ►�►�' . �
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Sanitarian's Signature Date Completed
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Amount paid ��Q'�
Receipt /� � ,,201 Z
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Improvements Permit.(Established/Recorded Lot)
�t�ovements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
_ Improvements Permit (Addition)
�- i�-`�5
Date
,. . ; .
y �.� , if � �
,:
. ...: : .. '. r �... �.wi _.'T.1,.. �.r*i t .. ,.. �.....
�einspection of Existing System (Loan
Repair/Replace existing Septic System
_ Pecmit foc New Well
_ Replace Existing Well
l. Permit requested by: .
owner/pros ,ective owner/ g
tAddress: � -1
��O `�C 4 rL �o %1/,
Home Phone #:� —
Business Phone #:��"L�"
N� and
�. .
. Property Descri�
. Tax Map#:�
Parcel#: 7
Townshi�
`. 7. Dimension or Proposed Structure:
nt:
!�! t�_ Width: °
. � U�� n 1 _ Depth:_ �,
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to secve?
of curren[ owner: ' 9. Wat r upply t}'pe:
� � `' private�. public ❑ community ❑ spring ❑
� Are arzy wells on adjoining pcoperty?Yes ❑ No j�.
If so, identify location:
. Lot size:
. Directions to property: State Road #& Road
iames. �tc. .> �
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Number of occupants or people to be served:
10. Type of structurelfacility: Proposed: �Existing: Q
Type of dwelling:
House: ❑ Mobile Home�Business: ❑
Type of business: �� �
Number of Employees:
Number of bedrooms:
Garbage Disposal? Yes N •
Basement? Yes ❑ No If o, # of basement fixtures:
� CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORI�IERS OF ALL
PROPOSED STRUCTURE,S.
�hereby make application to the Persort CouIlty Health Department for a site evaluation for the on-site
sewage disposal system foc the above deseribed property. I agree that ttie contents of this application are true
�d represent the maximum facilities to be placed on the property. I understand if the site is altered or the
�ntended use changes, the permit shall become invalid. I understand that before an Improvements Permi[ can be
issued, I must present a survey pla[ of the property to the Health Dept. I understand that in the event I have not
�ered a survey plat of the propercy to the Health Dept. within 60 DAYS after the date oE the evaluation of
the site by the Health Dept., this applicatior s�hall become void and all fees paid forfeited.
� .:, �--�°�..� a ��� r
Si'�ji e, Own�'r or Auchorized Agent
a
1377 1336
St7E `
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1394 1337
CEFFO
i3ao
1336
VICINITY MAP
BENNIE M. OAKLEY
D. B. 100, P. 187
5•50'12`E IS
2 50
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1 . �4�l� °' S85• 46'05'E
0� �, 187.75'
ACRE N ��—__ MP
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BENNIE M.OAKLEY
D. B. 100� P. 187
IS
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Person County Health Department
Existing Sewage System Report For: '� Mobile Home Replacement
Requestee:
��
Addition
es � l �� � Home Phone#
gs . ' '� �
susi ess#
� /�i�CJI �� / Y l� �� 'i� Tax Map# Olv''�c05
�ill//�! �_ �n << II/l� I� 11� �/� _�ll/�/l iF�
0 riginal Permit Located _
Septic System Ues ned For:
ltesidential f3usiness
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Other (specify)
# Bedrooms �_ # �mployees Other _
llate '1"nstalled ���Z �� Water supply �� `�
Type of System �b(1V en�-� Olr��
Nitrification Line "l ���,� �
Tank size
Certified Operator Required I�{ V
On site wasL-ewater disposal system showes no visually apparent
malfunction on �
Yermission is granted to:
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According to tt}e attached site plan. ,,,,
Comments: