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PERS�N COUNTIF HEALTH DEPARTMENT
SEWAGE DISPOSAL . ' .
IMgROVEMENTS PERMIIT NO
Issu ; Date: �.�f �p—
Owner: A
Location: � � ��
Septic Tank Contractor:
Building Contractor:
Water Supply: Private Public
All wells should be 100 ft. from sewer system.
Lot Size:
Sewage Dispos F cilities: No. bedrooms
Size of ta Nit ific ion li e:
Other disposal facility: / 3 �
Water supply and sewage disposal facilities location, inst lation and
protectiion must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be
maintained by owner in such a manner as not to create a public health
hazard. Septic tank a�d nitrification line MUST BE INSPECTED AND
AP�ROVED BY A MEMBER OF THE PERSON CO. HEALTH DEPARTMENT STAFF BEFORE
ANY PORTION OF THE INSTALLATION IS COVERED AND PUT TO USE. THIS
PERMIT VOID AFTER 3 YEARS.
Date Well Approved: .�
BY � �,�Q� �r l t J
Date Sewage Disposal App o�
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By:
—�v�-z•
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Signed
a 'tarian
Counter-
signed
(Own or his ep ntative)
Certificate of Completion ;j
Date Approved: �D "��� L b By.
Sani ian
(Over)
Location of well and sewage disposal facilities sketched'on back.
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WELL PERMIT ' • �
Caswell-Chath�m-Lee-Person Counties
DATE ISS ED: -� DATE DRZLLED: ' COUNTY: ,
OWNER: ROAD/STREET:
ADDRESS: PERMIT VOID AFTER ONE YEAR
DRILLING CONTRACT R:
NAME ADDRESS
WELL CONSTRUCTION
Distance from Ng arest Property Line Distance from Source of
Pollution� ,{�yt
Total Depth• Ft. Yield: '1 GPM Static Water Level: Ft.
Water Bearing Zones: th: Ft. Ft. Ft. Ft.
Casing: Depth: From � to Ft. Di er: Znches
TYPE: Steel Galvanized Steel
If Steel, does owner appr Yes No
Weight: Thickness: Height Above Ground: Znches
Drive Shoe: Yes: No:
Were Problems Encountered in Setti�the Casing? Yes_ No_
Zf 'yes" give reason: �
Grout: Type: Neat San ment: Concrete
Annular Space Width �Inches
Water in Annular Space: Yes No �
Method: Pum ed sure Poured
Depth: FromP to�5 Ft.
Materials Used: No. Bags Portland Cement Weight of
1 bag lbs.
• If mixture (sand,.g,iavel, cuttings) - Ratio: to
ID Plates: Yes V No Chlorination: Yes No
4 x 4 slab Yes� No
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION ZS CORR T AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE EGU IONS SET FORTH BY
CASWELL-CHATHAM-LEE-PERSON DIST. H T
Signature of Contr tor Date
FOR HEALTH DEPARTMENT USE ONLY
REASON FOR NO INSPECTION:
: �01 �
Sanitarian' ignature Dat
Sketch well location on reverse side. Use establis reference
points.
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Site Evaluation Application Date:
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Fee Collected YES ✓ NO ' � • '
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� ���,q� APPLICATIOK FOR IMPROVIIfENTS PERHIT
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1. Permit requested by
Address: �'t' � �
Home Phone ���
owneriprospective owner:
agent:
�ok g�G Se�
2. Name and address of current owner
Business Phone ��r`:
SQ �n �
3. Property Description: Lot size: �/'�C-��
4. Tax map ��: 1va�- 02 � Township : C u��U �� ���
Subdivision Name: Lot ��:
5. Directions to �roperty: State Road �� & Road Names, etc.
Atl� C,l�ees I�l� \\ '�c� - Beld.� C�-��o F� lre
o�Se 6
6. Permit requested for: New Installation: Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served:
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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?
$�.��c�. S�-o�Q� Q1�.�. O s� � rope�r� .
10. Water supply private? public? _
Other source? (Specify):
Are there any wells on adjoining property?
11,
community? spring?
If so, identify location:
Type of structure or facility: Proposed: Existing:
Type of dwelling: House: Mobile Home: Business:
Type of business: Number of Employees:
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 h eby granted to
enter the property for the evaluation. G.S. 130A-335(
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S ed Owner or A t orized Agent
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Permit Issued
Permit Denied
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Plat Observed
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i�ACTORS - SITE EVALUATION AREA 1 AREA 2 ARF.A 3 AREA 4
S S S S
1. SLOPE (X) PS PS PS PS
U U U �T
2. SOIL TEXTURE (i2-36 in.) S S S S
(SandS, loamy, clayey, PS PS PS PS
Note 2:1 clay) U U U U
3 SOIL STRUCTLTRE (12-36 i.n. ) S S S S
(Clayey soils) PS PS PS PS
4 . SOIL DEPTIi (in. )
S. RESTRICTNE HORIZONS (in.)
(Impervious Strata� rock)
6. SOIL DRAIIIAGE/GROUNDWATER
(bcternal & Internal)
7. SOIL PERMEABILITY
, (Percolation Rate)
U
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PS
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PS
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PS
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PS
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PS
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PS
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PS
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PS
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PS
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PS �
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PS
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g. OTHER (specify) P5 PS PS PS •
U U U U
9. SITE CLASSIFLCATZON
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECOMMEEt1llATZONS / CO2�4fII1TS :
S:�=TE CLASSIFICATZON DIAGRAH (Include: Soil areas, property lines. roads. streams, gullies,
Wet areas. fill areas. crells, water bodies, slope patterns, etc.)
A OL96
_ ' " PERS014� C.��TJNTY I�EALTH DEPARTMENT
WELL AND SEWAG� SITE, T.00ATIO�1 IMPROVEMENT PERNIIT
Tax Map # -- ,� Parcel #
Zoning Township %' C` t�v� n i' r� a n1
Owner/Contractor_ _ �U G1� � l 1 � �/ Date � ` � .- /� 9s'
Location/Address 7--
s.R.# �„�3
Subdivision Name
�YoUt
Lot#
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SEWAGE SYSTEM SPECIFICATIOlVS
Repair Lat Area � C, �. Size of Tank_ �� ��,
SFD Mobile Home Size of Pump Tank_ �� �
# of Bedrooms Nitrification Line l��� �'K 3�
�—�� Max Depth Trenches IJ ) i�
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altere i nd use c nged.
Well and Septic Layout by
Comments:
Date -
Indi idual
Public
Site Approved
Well He pprove
Gr mg Approved
Comments:
Date ]
This report is based in part on u
environmenta! health specialist is not responsible for false or misleading infonnation 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 ot misleading
statements provided to him in the application Neither Person County nor the environmental health specialist wazrants ihat the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�pemtitsam O1/95 rev.1.0
Installed bs/ 1(n ,�'
Approved
WELL SYSTEM SPECIFICATIONS
Semi-Public
.Required Slab
Air Vent
Required
WeIL�
ORIGINAL
06
Amount paid ��a'
Receipt �i ' 1
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provements Permit.(FstablishedlRecorded L,ot)
ImpFovements Permit {Un�ecorded I:ot)
7- I�- ��
Date
Reinspection of Existing System (Loan Closing)
_, Repaic/Replace existing Septic System
Improvements Permit (Mobile Home Replace) _ Permit for New Well
Improvements Pernlit (Addition) _ Replace Existing Well
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Bacteria » Chemical Petroleum ._,Pesticide
1. Permit requested by: .
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usiness F
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#: �
ame and addre&s of current owner.
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3. Pro
Tax Map#:
Parcel#: _
. Lot size:
Directions t �r�rtyo�s�Road#���toad
mes,,�tc. ,�,P � �
i.,, ��- „��, ;� e b�e.� o r e_
�7. Dimensions or Proposed Structure:
Width: , �Z � x �
_ Lead
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
9. Water supply ty pe: -'
private� . public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes� No Q.
If so, identify location:
I�Iumber of occupants or people to be secved: _
I0. Type of structurelfacility: Proposed: DExisting: Q
Type of dwelling: —/
House: � Mobile Home: �'Business: ❑
�ype of business•
Number of Em�loyees:_
I�Iumber of bedrooms: 3
Garbage Disposal? Yes ❑ No�
Basement? Yes ❑ I�Io�so, # of basement fixtures:
CLEARLY STAKE ALL CORI�IERS OF THE PROPERTY AI�ID THE CORNERS O� ALL
PROPOSED STRUCJ'URES•
I hereby make application to the Person COIInty T.-�ealth Department for a site evaluation for the on-sitc
sewage disposal system for the above described property. I agree that the coneents 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. I understand that before an Improvements Permit can ti
issued, I must present a survey plat of the propercy to the Health Dept. I understand that in the event I have noi
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept �s a plication shall become void and all fees paid forfeited.
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` - ., Person County HeaLth Oepartment
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Existing Sewage System Report For: ✓ Mobile Home Replacement ''r�
Addition
Requestee: �i�`-�l.�P����- �P�"�- Ha�►e Phone#�S JL�3
q�� M� �h�`��i��_ Business#
� Qilm� I c/� .► V C` ���'7� 'fax Map# 2g���
Location/Directions:
Original Permit Located v
Septic System Uesigned For: �_
Kesidential �✓ Business Other �specify)
# f3edrooms � # Employees Other _
Uate Installed �-��- g� Water supply ����
TYpe of 5ystem i1 v�/ ��U � -� �� D!�
Nitrification Line �W1�.31 v -
Tank Size vV�
Certified Operator Required � �
On site wasL-ewater disposal system sliowes no visually apparent
malfunction on �/� � / `� . �
Yermission is granted to:
According to the attached site plan.. -
CommentS:
` � � �/.�'� 17i/� �l �