A25 179♦' �
•_ Site�''Evaluation Application
„ ,,, .,�' _
Fee Collected' YES� /
U
� �D�. a6 � �3
i' � � I 3 q. ��i
C°' �e �
♦
Date: `�, /�1//��
�i]
APPLICATZOId FOR IMPROVII�SENT� PIItHIT
1. Permit requested by: owneripruspective owner:
,� agent:
Address: �� Zfl Y W�ti/J- l.%ta
Home Phone ��: 3�P-S'3�v Business
2. Name and address of current owner:
3. Property Description: Lot size:
�
one a� :
�
4. Tax map �'l�: - -�.� Township: ����(�cJGi.��t % ��"«��
Subdivision Name: Lot ��:
S. Directions to property: State Road �� & Road Names, etc.
�
6. Permit requested for: New Installation: � Repair:
Additional Renovat'on re-using 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? If so, identify location:
11,
12.
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 To
Basement? Yes No �If so, number of basement fixtures:
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. Per ission i h e granted to
enter the property for the evaluation. G.S. 130A-335(
G~� '
Signed Owner or Aut "rizeci Agent
z
m
�
9
H
w
�
i�
r
0
r+
�
b
�
H
�
i �,,
rt
�
Permit Iss�ed �
Permit Denied
Plat Observed �
� _. _
� �
r-► �
��
/
' � .,
'� .�
i�ACTORS - SITE EVALUATION AREA 1 AREA 2 ARF.A 3 AREA 4
S S S S
1. SLOPE (�) 'S, U_ �a PS PS PS
� U U J
2. SGli. TEXTURE (i2-36 in. ) S S S S
(SandS , loamy, clayey, ��. `n� PS PS PS
Note 2:1 clay) `�� U U U
3. SOIL STRUCTURE (12-36 in.) S S S
(Clayey soils) P S-� PS PS PS
U U U
S S S �^
4. SOIL DEPTH (in. ) ��'j � u PS PS PS
U � U U U
.5. RESTRICTIVE HORIZONS (in.) S S S
(Impervious Strata. rock) P` �jJ PS PS PS
U U U U
6. SOIL DRAI2�IAGE/GROUNDWATER S � S S S
(bcternal & Internal) � o PS PS PS �
U U U U
7. SOIL PERMEABILZTY S S S S
(Percolation Rate) PS � 3� PS PS PS
u u u u
s s s s
$. OTHER (specify) PS PS PS PS •
U U U U
9. SITE CLASSIFICATION � �
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECOY�4SE21DATIONS / COMMFSITS :
S:�TE CLASSIFICATION DIAGRIIM (Include: Soil areas, property lines. roads, streams, gullies.
Wet areas, fill areas, Wells. water bodies, slope patLerns, etc.)
�
W
�
a
�
�
�
B 1328
PERSON COUNTY HEALTH DEPARTMEN'I'
._ WFLL AND SEWAGE SITE, LOCATION IlVIl'ROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # � a,� Parcel # I 7�f
Zoning Township rn ►
Owner/Contractor _ ' L ' ,��( WC�,�4� �, �ahC�l�,/D te (o
Location/Address f5 F� d� 5, � t 3 3�o
� — S.R.# � 3 3l�
Subdivision Name CAw�e ncP C f�w +b nl Lot# 2
SEWAGE SYSTEM SPEC"I�'ICATION�
Repair Lot Area /� U�}c�P Size of Tank I 0o O
SFD Mobile Home ✓ Size of Pump Tank /�
usiness # of Bedrooms 3 Nitrification Line �l�o' x 3�
Max Depth Trenches a(v %�.
Permits may be voided if site is altered intended
Well and Septic Layout by }� � ��
Comments:
Date
ell Permit Paid
Installed by,
Semi-Public
Site Approved
Well Head Apnrove�
Comments:
Approved
� r1 3D
SYSTEM SPECIFICATIONS
Required Slab
Air Vent �
Required Well
Well Tag �
_ a _ _
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The environmental 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 the water suppiy will remain potable.
c:�amipro\permit.sam O1/95 rev.l.l
. ; =�;;�;ss�'`�� _
IS
�EL B
F • NOEL
�:.4:'��r. -.
�� ��
. . . . . . .. _- . �I ��
�1
( <�..�� -�
' �
� �9�3 �2,3 „E
PR�pOs ' rs
� , ,
�_ Ep �
, �,,` o� S�s.o
�-
3 ;� on/ �.. s� � .q C 29g '4�3 "E .
ls� �;\` C'�S`s
1 . 20 . A C , � r�N,B, �q � : ,�„j Eqs�M
IS 6> 92 � \ '-�//! � �' �o ��T
St t •58'Ot �� I� 8�-a '' �,?i•
'� 3� 9� 84 � 90 . 00 � - i, a�� � _�. ' ; �
:�'�'�/` ��. 1-
� Sg u�, DRA I NF :,r ,� .•
EASEl1E�Ni ..�t�s�_ �. cv �'
_ � •-
� � ��
IF
�v�
IS Bp.Op;. �_ �S 2
<
1� iv7�. �•'l.:,
P�� �� �59�,h,
p pW�
R� I N
E Ri%�/
//
� ,��ij�
�
�
�� � �� �
��
��
�g�
(���s ,i�
CARO� INA PERSON COUNTY '�z%�vI -I Z
NF.�4(,- -� 1{�U'11E1T
�HRE�TES A -"----• �ERTJFY THAT TH(S
SUBDIVISION OF LANp wI7H1N
- COUNTy, ri17NESS MY HANp ,IHp SEA� THIS
1Y OF _--�Y----. 19 9� _,
i
f .k�I � _. . '
STfN� Srl, Ky��..5: .
A�. q,
. t� � C(-'���� /
. . F> , �,
, .��.'�`��C�M��y� �,/ _�NF
�
14T � � � �
f ; � �
' C. 9, f; 51 •7 � : /
' / /' �
,�`'�' .i; ' i ,� � � �
� ,� i
� ;' i �:6J'S8 �
; � NF' � �� . �, 56 . 7t
� n
� i� � i�.1
j , � �:
i �. � NCGS "F3IRG
�-� � tJ = g91 , 66
i %�' j' F= 1, 986 ,.
' ,�, ;` CGNTROL
/ ' ' COkNFR
�� .�
�.� �'
�
���
.
�l
/ �
. �
PERSON COUNTY ENVIROril�JEPITAL HEALTH ' . •
�
Date: ' � '
Owner. c�..�c�-�� �
LocationjDirections:
Subdivision N�une:
Drilling Con�ractor:
WELL LOG
SR#
Lot #
. . .. w.a c �� . »,
• '. v.�,� `. e:
_ . r,,,. _ ,.
l:
�.
WELL CONSTRUCTION � ---
Distance from Nearest Property Line /O Distance from Source of
Pollution �� '
Total Depth: l�'b Ft. Yield: �` GPIv1 Static Water Level a��
__Ft.
Water $earing Zones: Depth �OJ Ft. Ft� Fc. �[.
Casing: Dept}l: From G to��( Ft. Diameter:��(�_�ches
TYPE: Steel � Galvanized Sceel �'
If Steel, does owner approve: Yes No
Weigh[: Thickness:� Height Above Ground:� Inches
Drive Shoe: Yes / No
V,�ere Prcblems Enc�tmtered in Setting the rasing? Yes No �
Zf "yes" give reason:
Grout: Type: I�Ieat Sand/Cement � Concre[e
A.nnular Space Width Inches
Water in Annular Space: Yes No
_ .. Method: Pumped . . Pressure � � � Poured �'.._ . . - �, : -
Depth: From ('�_ to ae� Fc. � �
v
Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes � No � � �� �
� 4 x 4 slab Yes ./ No
I HEREBY CERTIFY THAT THE ABOVE TNFORM�ITION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED lN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSO�I C�Li�1TY HEALTH DEPARTMENT. �
..� w Q V
� ignaturc oE Contractor D1tc