A25 178Site Evaluution Applicntio:�
Fee �EC't"*P,'cted YES �
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Date. �, ��Z'
APPLICATTOI�1 FOR IHPROVEhiENTS
1. Permit requested by: ownerf�rospective owner:
agent:
Address : � • � Y l/l�/Uyti�- ��1.�.��
Home Phone ��: 3'i9-�'3�'� Business F
2. Name and address of current owner: �
3. Property Description: Lot size:
4. Tax map ��: - -lS
Subdivision Name:
5. Directions to property:
j'1 �1 �G��,
Township: ��i�,c.(ic/�j�.)�Lt % ��"�/rr`�
Lot ��:
State Road �� & Road Names, etc.
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6. Permit requested for: New Installation: � Repair:
Additional Renovat'on re-usirig present system:
.
7. Number of occupants or people to be served:
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? community? spring?
Other source? (Specify)•
Are there any wells on adjoining property?
11,
12.
�
If so, identify location:
Type of structure or facility: Proposed: � Existing:
Type of dwelling: House: Mobi e Home: Business:
Type of business• Number of Employees:
Number of bedrooms: Garbage Disposal? Yes I�o
Basement? Yes. No �If so, number.of basement fixtures:
Clearly stake a17. corners of the property and the corners of all proposed structures.
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I tiereby 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 i5 altered or the intended use changes, the permit shall become invalid.
Permits are valid for 60 months from date of issue. Per ission i h e granted to
enter the property for the evaluation. G.S. 130A-335( �
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Signed Owner or Authorizec Agent
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Permit Issued / �� �
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Permit �%
Plat Observed
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l?ACTORS - SITE EVALUATION AREA 1 AREA 2 ARF.A 3 ARFA 4
=S S S S
1. SLOPE (X) PS PS , PS PS
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2. SGli. TEKTURE (12-36 i.n. )_ S S S S r
(Sand}�, Ioamy, clayey, �S',� � PS PS PS
Hote 2:1 clay) U U U U __
?. SOII. STRUCTURE (12-36 in. ) S S S S
(Clayey soils) PS S�%� PS PS PS
- U U U
S S S S �
4. SOIL DEPTEi (in._) _ ���{, �� PS - PS PS
U U U
S. RESTRICTIVE HORIZONS (in.) S - S S
(Im{�ervious Strata� rock) �� N� PS PS PS
- U U U U .
6- SOIL DRAItIAGE/GF.OUNDWATER S S S S
-(bcternal & Internal) PS �J� PS PS PS �
U U U
7. SOIL P�RMEA3ILITY S S S S
(Percolation Ratc) PS G'3 � PS PS PS
U U U U
� S S S S
g._ OTHER (specify) - PS PS PS PS '
U U U U
9. SITE CLASSIFICATZON �
(See belo�a) �
`' "RIES
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�.' - Sui.table PS - Provisionally Suitable U- Unsuitable _
RECO�t1UAT. NS/COMMIIITS:
�:�TE CLASSIF..CATZON DTAGRAii (Include: Soil areas, property lines. roads, streams, gulZies,
c.ret area� . fill .�reas, c�ells, water bodies, slope patterns, ete.)
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., PERSON COUNTY HEALTH DEPARTMENT
� WELL AND SE'vV�GE SITE, LOCATION INIPROVEMENT PERNIIT
Tax Map # ���j Parcel # f% S
Zoning Township �. v ���'1 � n �,�i,a .r�
Owrer/Contractor � G G � � � m �'a� �'"' _ ��_
Location/Address �
. S.R.#
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Subdivision Name
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Lot#
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SEWA E SYSTEM SPECIFICA I NS
Repair Lot Area /• 7l cr� � Size of Tank '<"
SFD Mobile Home�_ Size of Pump Tank �'-�.�
Business # of Bedrooms�_ Nitrification Line � S"v' X
Max Depth Trenches ��, "
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered nt nded us changed; '
Well and Septic Layout by � .
i
Comments: �
Date�� �-� C� Installed by � (�iS Approved
' � � WELL SYSTEM SPECIFICATIONS
Individual�_Semi-Public Required Slab �
Public Replacement Air Vent �,i'
Site Approved � Required Well Lo�
Well Head Approved Well Tag
Grouting Approved
Comments:
.,
;
, ���� ���,.,� � �� ���� �, �,a, „�� ��.,�.��a.,.,,. r ................ ......._.,:...-• -- --; ---- -�: ------. - - _rr _ _ ,
envirorunental health specialist is not responsible for false or rrusleading mfonnat�on contamed in the application. The envuonmental health specialist
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 warrants that the septic tank system will
continue to function satisfactorily in the future or that ?he :vater supply will remain potable. c:�amipro\permit.sam O1/95 rev 1.0
ORIGINAL
�7/12/1995 �8:12 8044547843 BENNETT WELLDRILLING PAGE 02
Ju»-Z7-96 d8:46A PERSON COUNTY HEALTt•1 O �.02
PT;RSON COUNTY FNVi RON�iF.f�Th� HF:AL'fH
Ur•.r,L �,OC
v3tC: 7• ./� � gs' .
Owner:. -- SFt�I . L33�-- —
Loc;ation/Directions: ��2 .. �,�,� �.�. _—
Su�diti-i�.i�r. Namc� �a,.,�,,,�u. �,�, S/�p—'_� .._.� ..� �
Drilling , _'����� � — — �-- �.�i it�----- -
COn trlc.tOr: .��.�� �i s�GG
w�tt, cQNSTR��TInN — —...._._ _ _ —
Dist;tnce frnm Ncascsl i'roperty Linc,_1U __ Dict,�nc;a t�rc�,n Sovrcc: of
I'ollution
i'otal Depth:���, Ft. Yield:�,�_ GPM St�tic Water Level � p _,Ft.
Water BcaTing Zones: Depjh �,p�p�,��t,�F� �Fr.
Cusing: Dcplh: From��„to�_�F[. Diatnetcr:,,^��Inches
TYPE: Stcel Galvariir.eci ,Sce�t�/
1f Stcel. clocs owrtct approvc: Yes`��N� �.
Weight:,�„(�.�'}iic��s:� Hcig,}u Abc�ve Gfound:��_ Incttics
Drivc Shoc: Ycs ✓ . No„`
Wrre I'robIcros Encountctod in Sctting thc Cnsin�? Ycs� No � '
IC }cs gi�� r:.ss�n: -'-Y
C�rout: Typc; Ncac �/" S1nd/Ccment_ �C,'oncrctc �- •
Annular Spacc Width,�3� tnchcs
Water in Annular Spacc: Ycs N�� /_
. Mcthod: RunP�=cl�_ Pressure �'oureci ✓
Acpth: Fr�m— /,� co � D _ _Ft. -_...�"
Matcria�s Used: No. $ags Ponland Cemcnc�� W�;�g},t of 2 ba
JFmixturc (scu�d, $ravel, ee�ttings) - Ratio;_� , ��` � —�hs.
I�7 Piatcs: Yes_ ✓__, No�� .� `-`
4 x 4 s]ab Y��` No
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I H�REBY CER'iIFY THAT THE AAUVE INF(�}tMA'i'tON lS CORREC'1' ANU 1'HA'1'
TF�S WELL WAS CONSTRUCTED TN ACC4Ri)ANC'E V��1't"H RFCULA'17r�NS SET
FORTK AY•711� PEKSc�,` c�;;u„r�• HEA�TH D�ynR'TMEN'('.
—; `--��� 7 �� qs
Sibnaturc uf Ccmtract�r -- — -- � � 17.�i,•