A25 169Improvement Permi
l 1
APPLICATION FOR:
( ) Subdivision
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Date Received:
2
( ) Other � �
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Permit requeste by: ~ � Home Phone-�P9- '����
Address : �o �t � '"" .l�r-t' � �/ BusT eS�s, Phone�`��' �
��►' Ore /l/, �, �%.f` ��r'✓e` /�, n/t y c�a.�/`
. �/''� .�`,z a
Name and address of current owner:�" '� ���
..1 �a f.�. e j .i y . '-* .
Property Descrription: Lot s�j.ze �� '� -��� Dimensions: �
Front �'� Left .�%�° Right -�'�� - Rear �Sd
.��f, ��� ' a..r. /`�r.o-�� .
�ti �..,.�i� �
Tax map No. Townships Block. No. Lot N��'�'Z
5. Di�r� ctions to ro er S ate d �16,. & Ro d s, etc
/Y�✓� .�`% p..p � ��/'.�� � � �''-��o^� —
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% i-� � K o • � . c � �r o. ,1'.�
. ����i � c I'^i rf� , �..J�7%. � % �� /" „' .o ✓
. i�/-✓jyr r } O �V . e� � /iaJ !' r ../' G C` 'n� .
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6. Psrmit requested for: New Installation Repaired
Additional Renovation re-using present system
7. Number of occupants of people served ? �� �,�,��� ���
� �
8. Dimensions of Proposed Structure: Width - Depth
9. What tyge (if any) additions, expansions, or�replacament is an�icipated
to the structure or facility that this sewage disposal sys�em is intend
to se�-ve? �
10. Type of water supply:
supply:
pr,o�erty�. � �'`'I sg,��i
f � �
11.
12.
Well �yes no: If no, name source of water .
Are there any ls n d' inin
ntify location. �� �` ��� o � /
� `� ./
Type of structure or acili � Proposed v Existing
Type of dwelling: Hovse �• Mobile Home Business.
Type of business �� Number of Employees ��
Number of B�drooms Number of automatic appliances ''
Basement - Number of basement fixtures �
Clearly stake all�carners of the property and the corners of all prop
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 a proval of the
Person County H�alth Department. Permits are valid for�onths from dat
of issue. �O
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FACTORS - SITE EVALUATION AREA 1 AREA 2 AREA 3 ARF.A 4
S S S
1. SLOPE (X) PS !� � PS �
S. "' U
2. SOIL TEXT[TRE (12-36 in. ) S �'"- S S r�
{Sandy, loamy, clayey, PS � 3p'� `�' PS �� �� `� PS 3��� � �� �
Note 2:1 clay)
3. SOIL STRUCT[TRE (12-36 in.
(Clayey soils) �
4. SOIL DEPTH (in.)
5. RESTRICTIVE HpRIZONS (in.
(Impervious Strata, rock)
6. SOIL DRAINAGE/GROUNDWATER
(bcternal � Internal)
7. SOIL PERMEABILZTY
(Percolation Rate)
PS
PS
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8. OTFiER (specify) PS PS PS � PS I
' • U U U U
9. SITE CLASSIFICATION
(See below) � . � � S � �
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
RECOI�II�SENDATIONS / COMMENTS :
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies,
wet areas, fill.areas, wells, water bodies, slope patterns, etc.)
At�niication Date: 5"Z'b�
Amount Paid: ��
Receipt #:
�_�� �� I�'II�I�� �l�T
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�1�aava.ac-oaa.�-�-� m�.�io.Il �3C�m71�ILa
APPLICATION FOR SERVICES
Tax Map #:
Parcai #:
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED,
CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AiVD AUTHORIZ,4TION TO c,(�
CONSTRUCT SHALL BECOME INVALID. � \�W�'
1) Permit requested by: ��gentlprospective owner • � � .v.` � � /'��.f
� `
Home Phone: .1� -Oo Address: v� s.� �� r�
Business Phone: /�-� L dii+ •�� 7� � �
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2) iName and address of current owner % ' . ��G.� �
4 t.
��� �� � y d •
,����.� ,� c. �z � � ��-�
3) Property Description:
Directions to the prope
R'G��-Township:
4) P'roposed Use and Structure Description: answer each of the following questions:
a) Proposed _, Existing Type of Strucfure: Width
b) Number of Bedrooms: �� Number of occupants or people to be served: �_
c) Basement: Yes� No �/ Will thele be plumbing in the basement?
d) 6arbage Disposal: Yes No ��
Lot #
Depth:
5) Water Supply Type: Private ~(new _ or existing�, Publ _, Community� Spring _
Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the
� site plan.
6) Does your property contain previously identified jurisdictional wetlands? Yes_ No�
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPER'TY QR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATIOM.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED. �,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAFCED OR FLAGGED. -
9 THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF.
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 piaced on the property. I understand if the site is altered or the intended use changes, the permit shali
be.clome-invalid. � B� � _
Gt/. r
Representative
.S � - d S
Date
PCND, rev. 06l27/02
� � � - A 0410
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P�:RSON CC)T..JNTY HEALT�I DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
` i ax jNiap # 1��� Parcel # t��
Zoning Township �.(n � i n
(3wner/Contractor � 5 .. 3� S Dat
Locatiot�/Address �j�av.�a� C�� fiW S N 'o ord —C T
�1'1 (� 5 M i I l L �p n S.R.# 137r1
SubdivisionName Lot# �_ �
Layout
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SEWAG� SYSTEM SPECIFICATIONS
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Repair Lot Area !, D Ac �P Size of Tank DC7
SFD � Mobile Home Size of Pump Tank N A
Business # of Bedrooms_� Nitrification Line �L` �
M� Depth Trenches ?(o
Pernut Void after 60 months. Pernut Void if not in compliance with zoning regulations.
L
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Permits may be voided if site is al red r intended use chang d. Sep a��
Well and Septic Layout by a � a��e� r er�+
Comments:
Date
Installed by
Approved by
WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab
Public Replacement Air Vent /►
Site Approved �/ �.equired Well Lo�
Well Head Approved ✓ Well Tag
Grouting Approved �
Comments: �
Date
7�his repor( is based in part on infortnation provided tt�e homeowner or rus�ner represeniavve m uie appncauon suom,uc�, .vr u�u �,,,��. . ���
envaonmental health specialist is not responsible for false or misleading infocmation contained in the application The environmental health s ist
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 wazrants that the septic tank system will
continue to function satisfactorily in the future ot that the water supply will remain potable. c:�amipro�permitsam O1/95 rev.1.0
ORIGINAL
m
.L�ate: o '
Owner: �
Location/Directions: _
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
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Subdivision �Name. ___ � Lot # +
Drilling Contractor: _I�� ►,h� ene� '
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� WELL, CONSTRUCI'ION '�
. F;.
Distance from Nearest Properry Line ,(S-� Distance from Source of
Pollution /60� ` �
Total D.ep.th: /�/G ` Ft. Yield: GPM Static Water Level d.s' Ft.
Water Bearing Zones: Depth s�0• Ft.��F� Ft� Ft.
Casing: Depth: From C� to �/� Ft. Diameter: ��/y Inches
TYPE: Steel � Galvanized Steel '�'
If Steel, does owner approve: Yes No
Weight: Thickness: /�� Height Above Ground: / y Inches
Drive Shoe: Yes .� No �
Were Problems Encountered in Setting the Casing? Yes No .�
If "yes" gi�-e reason:
Grout: Type: Neat SandJCement -- Coricrete
Annular. Space Width Inches
Water in Annular Space: Yes No
. _ Method: Pumped . -- Pressure � Foured --� . . . . -
Depth: Fr�m d to a o Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes r No � �
4 x 4 slab Yes / No
I HEREBY CER`I`IFY THAT THE ABOVE 1NFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON CCUi1"I'1' HEALTH DEPARTMENT.
Signature of ontractor Datc
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