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Tax Map #
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Owner/Contractor
Location/Address
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Subdivision Name
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EALTH DEPARTMENT
iEWAGE SITE, L CATION Il�IPROVEMENT PERiVIIT ` '
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SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area �� 57 Acres Size of Tank I Opd
SFD Mobile Home ✓ Size of Pump Tank �J /a
Business # of Bedrooms 3 Nitrification Line 3Gb ` K 3'
Max Depth Trenches ��;n .
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or intend�i se nged.
Well and Septic Layout by � '
Comments:
Date
Installed by /►,t, L�t,� �'s Approved by
Site Approved_l/
Well Head Approved
Grouting Approved_
Comments:
WELL SYSTEM SPECIFICATIONS
Semi-Public Required Slab "
j�ilacement Air Vent
Required Well Lo� �%
Well Tag , �-
Date - .� _ nstalled by ���/Ct �1 � Approved tyy �,� ( �J ,��,L(�2
Ttus report is based in pazt on infocmation provided the homeowner or his/her representative in the applicatwn submitted for this pemut The
environmental health specialist is not responsible for false or misleading information contained in the application 'Ihe environmental health spe��ialist
is also not responsible for concealed conditions on the property or for slatements in this repoR that may have resulted from false or mislezding
statements provided to him in the application Neither Person County nor the enduonmental health specialist wazrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�pemut.sam O1/95 rev.1.0
ORIGINAL
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S�,�luation Application
Fee Collected YES � NO
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Date: �(� /l°I l cl `j' .+
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APPLICATT_ON FOR IHPROVEMENTS PERHIT
1. Permit requested by: owner{prospective owner: �,�
agent: '
Address: �o;,,��,r �l- ��sbc- nQ Qo� �R
Home Phone ��: Business Phone ��:
2. Name and address of current owrier:
3. Property Description: Lot size: S.S %
4. Tax map ��: f�-�� Township: �u1:���,,...
Subdivision Name: --� Lot ��:
5. Di(^rections to property: 5tate Road �� & R(�o d Names, etc.
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6. Permit requested for: New Installation: ✓ Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served: oC
C� v�ce- l
8. Dimensions of Proposed Structure: Width: Depth:
9. What type (if any) additions, expansions, or replacement is anticipated to the struc-
ture or facility that this sewage disposal system is intended to serve?
10. Water supply private? � public?
Other source? (Specify):
Are there any wells on adjoining propert
community?
If so, ident
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ifv location:
11, Type of structure or facility: Proposed: Ex ing:
Type of dwelling: House: Mobile Home: � Business:
Type of business: Number of Em yees:
Number of bedrooms: �_ Garbage Disposal? Yes No
Basement? Yes No �If so, number of basement fixtures:
12. 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 or existing system 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.
Permits are valid for 60 months from date of issue. Permission is hereby granted to
enter the property for the evaluation. G.S. 130A-335(F)
Signed Owner or Authorizen Agent
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Perm'rt�Issued
Permii 1�enied.
Plat Observed
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i�ACTORS - SITE EVALUATION AREA 1 AREA 2 AREA 3 ARF_A 4
�'js' S S
1. SLOPE Cx) � � 5�o PS GS �a PS PS
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2. SGIL TEXTURE (i2-36 in.) S S S S
(SandS , loamy, clayey, � C� � P C�rey PS PS
Note 2:1 clay) U r r U U U _
? SOIL STRUCTIJRE (12-36 i.n. ) S S �e�(� S S
(Clayey soils) � S p�.b � s�g PS PS
4- SOIL DEPTH (in.)
5. RESTRICTIVE HORIZONS (in.)
(Impervious Strata� rock)
6. SOIL DRAZIIAGE/GROUNDWATER
(bcternal & Internal)
7. SOZL PERMEABILITY
(Percolation Rate)
$. OTHER (specify)
9. SITE CLASSIFICATZON
(See below)
SOIL SERIES
S - Suitable
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PS - Provisi.onally Suitable _ U- Unsuitable
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RECOt��NDATIONS/COMMFSITS: (�isc� �1�.•l�n�t� r c-�� r.,.�to...�, ( c u c�. —
S:�:TE CLASSIFICATZON DIAGRf1H (Include: Soil areas, property lines. roads, streams, gulZies,
c�et areas, fill �reas, c�ells, water bodies, slope patterns, ete.)