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A26 101�,, � _ z Person Count� Heaith Department � Sewa e System Irr��rovements Permit Date: is Permit Void After 5 Years , Owner: • ' SR# 13y?_ ` � vt On � �{- t 6r�� /.o�s.r o�► h Subdivision Name: Lot # Lot Size: ,�'(� a W � Type of Dwelling: _ Water Supply: Private:—� Public: Community: Bedrooms: �_ Garbage Disposal � Basement ' Basement Fixtures II�ORMA D BY S�Il1I�t1�11: owne or rep enta[iv REPAIR: � REEV UATION: Size of Septic. Tank:1QaQ allons Size of Pump Tank: Nitrification Line: '� �� l�� Depth of Stone: 12 inches Max Depth of Trenches: � Altemative System: Conv. Pump LPP Pump T Remarks: Date��v� �� Well should be 100 f� hom any sewer system BY r►n.r Sanitarian _ BY anitarian I TI ATE OF COMPLETION Contractor. ------------------------- '� � Sewage System location, insLallation, and protection must meet state and local '� regulations. Septic tank should be pumped out every 3 to 5 yeazs and shall be maintained � by owner in such manner as not to creaie a public health hazard. Septic tank and'd nitrification line must be inspected and approved by a member of the Person Counry � Health Department before any portion of the installation is covered and put into use. If the site plans or intended use change this permit is subject to revocation. �(� � (G.S. 130 A-335F) � _ ��n � L.ocation of sewage disposal sewage system sketched on back. � � � . �� ^ (OVER) � -� -� P P � -� � ' � C,�-laY T6�S Gt�� G��.� ��- � . ,� Person County Health Department � W�ell Permit � Date: - S- D This Permit Void AftG� 3 Years '� Owner:.�� /�• ?�l:e �� # / 3 S� Z Locapon/pirections: � .�A' a• �p': �" / � � �. �`-. Subdivision Name: � � � �t� �,.�_ � Drilling Contracwr: ��—�+`. WELL CONSTRUCi'ION ►ti Distance from Nearest Property Line Distance from Source of �' Polludon � Total Depth: G Yield: �GPM Stadc Water Level F� � Water Bearing Zones: Dep� Fr � Ft. Ft.=-�L /� ,� Casing: Depth: Fmm �,Z to ��Ft Diametes: ,'�l ��Inches TYPE: Steel ' Galvanizeci Steelv ff Steel, does owner approv�� No Weighr. Thiclrness: Height Above Ground: Inches Drive Shoe: Yes No Were Problems Encountered in Setting the Casing? Yes No If "yes" give reason• GrouG Type: Neat S �ent Concrete Annulaz Space Width � Inches Water in Armular Space: Yes No / Method: Pumped Pres e Poured� Depth: From —� to Ft Materials Used: No. Bags Portland Cement Weight of 1 bag lbs. If mixture (sand �ave cuttuigs) - Ratio: to '�D Plafes: Yes � No 4 x 4-slab Yes No � � � I HEREBY CER'TIFY THAT THE ABOVE WFORMATION IS COR ECf AND THIS WELL WAS CONSTRUCTED IN C DANCE WITH ULATIONS SET FORTH BY THE PERSON COUNTY Signat�e of Contractor Date � �/.G22 a..�s�s.�./�,., °L.,,� �tst,.r-�4`s = 2s�� Sanitarians Sit";nature � Date Issued Sanitarians Signature Date Completed Sketch well locauon on reverse side. 'd � . � NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water su�3plies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located '� at later date. Note location of water supplies on adjacent lots. ■■■■■■■■■■■■■■ .■■■■■■■.■.■ ■■■■■■.■.■.■■. .■■■■■■■■.■■■ ��■��e��e��■�� ■ ■�� ■��■��N��■ ■ ■■■��■ ■ �■��■�v��■ ■��0■ ■��■ ■��■��■ ■■��■�� ■��5�■ ■■��■��■ ■�� ■��■�■��■ ■��■■a��■ ■��■ ■��■��■��n�■ ■��■■■��■ ■ 00 Amount paid . a: � �'� Receipt .4� ' 0 � H O � ,+.. . �i.PPLICATION �OR SERVI� �-3�-�`7 Date 1. Permit requested by: . ^ 7. Dimensions or Proposed Structure: I owner rospective owner/agent: ��EC /1. cG /r �. Width: � a� „ a a _�..,.. � � _� ,�'1., �� „ � �% � ► a. w• i� _ - Depth: ,.�fl � � w U � a W ¢ z 8. What type (if any, addi[ions, expansions, or replacement is anticipated to the structure or facility . that this sewage disposal system is intended to serve? ome Phone #: �/�� $99- 95�� usiness Phone #:�2/ )�97 3G� E�'r�u9t'`"`( d'�f y Name and addre�s of current owner: 9. Water supply t}'pe: ` �� - � � ` � j��,,f � private f� - public ❑ community ❑ spring ❑ � Are any wells on adjoining roperty?Yes ❑ No �. If so, identify location: �o �/ G : Lot size: • 90? �cr�-- Tax Map#: �4 � ��__ - Parcel#: _� 0 � Township: �/�� i � �.l l . Directions to property: State Road #& Road r/1 � dn iti'�Ll%'Dn �aC ( r 10. Type of structure/facility: Pro�osed: DExisting: Q I Type of dwelling: ST��a ge js"' �`�' "g House: � Mobile Home: L7 Business: ❑ Type of business: Number of Employees: Number of bedrooms: _ Garbage Disposal? Yes ❑ No 0 Basement? Yes ❑ No�7 If so, # of basement fixtures: r6 Number of occupants or people to be served: _.�� ' CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES• I hereby make application to the PerSOn COUIIty �Iealth Departmettt 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 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 be issued, I must present a survey plat of [he property to the Health Dept. I understand that in the event I have not 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., this application shall become void and all fees paid forfeited. Si�ncc� Owner or Authorized Agent Permit Issued ❑ Signature Date _ _, , Permit Denied ❑ ' • - Plat Observed ❑ '� � .:'s�`re ,. �'.r x...,. FAC7'ORSSITEEVAI.VA770N... . ,„„ "' .r ...;: .��?�s .<.'<., `. ARFJt2 ':AREA3...,> ARFAd ,. _ _ S S 5 S 1. SLOPE (%) PS PS PS PS U U U U 2 SOILTEXNRE(12•36IN.) S S S S (SANDY, LOAMY, CLAYEY. NOTE 2:1 CLAY) PS PS PS PS U U U U 3. SOIL S7TtUCiiIRE (12-36 !N.) S S S S (MYEY SOiLS) PS PS PS PS U U U U, 3. SOILDF3771(W.) S S 5 S PS PS PS PS U U U U 3. RESTRICIIVE HORRONS (IN.) S S S S (tMPERVIOUS STRA7A. ROCK) PS PS PS PS U U U U 6. SOILDRA]NAGF/GROUNDWATER S S S S (FJCfQtNAL & iMERNAL) PS PS PS PS U U U U 7. SOIL PERMFABII.TCY S S S S (PERCOLAATION RATi� PS PS PS PS U U U U E. AVAII.ABLESPACE S S S S PS PS PS PS U U U U 9. Sil'ECLASSiFIGT10N(SEEBELOW) SO1L SERlES SSUITADLE PSPROVISIONALLYSUTfAIII.E U-UNSUITABLE RECOMMENDATIONS/COMMENTS: SITE CLASSIFICATION DIAGRAM (Include:'Soil areas, property lines, roads, streams, gullies, wet areas, �11 areas, wells, water bodies, slope patterns, CCC.� C:�AMiPRO�DOCN+PPSEC.SM FINANCE.PC w � � � B 1 �82 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IlVII'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 # � �� Parcel # � (� Zoning - Township ,'/ Owner/Contractor � C� ,�, C a t�y, �r. Date 3- 3J- 97 Location/Address Subdivision Name 3r Lot# SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area ��`-12 �� cvc SFD Mobile Home Business # of Bedrooms � v V 6�ile a �,JT� P � �.n �� V Permits may be voided if site is altere � Well and Septic Layout by a Comments: Date Installed by �'Vell Permit Paid ❑ Individual ublic Site Approved Well Head Appr ed Grouting Appr ved_ Comments: ,, ,, Date S.R.# / 3 yZ Size of Tank .CR � ��r, Size of Pump Tank , _ Nitrification Line CC� Max Depth Trenches �— cha Approved WlE SYSTEM SPE ICATION ' ublic Required S] _ acement Air Ven Req ' ed Well Log W 1 Tag Installed by Approved by, This`re�iorf is based in part on inforfnation provided the I�6mg'owner�`his/her 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 eavironmental health specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:lamipro\permi�sam O1/95 rev.l.l . J.y..r�""�"rwi+ � � J _ J Q w e: � �....---- ' �, . IQ _ _ S17° 34' 04'E p 1 Q � 273.97' TOTAL . � � 31.51' , � ` i y 01% � � �� O ' � � � � Ai � , J j J � . ��j �. / ��. . 3,� � \ �- I � � �. . . ' . A'1 � � W , �" � �: _�„ �.. ro �. � O � .. �_ �, a � � f �' � �_ �_ �� / c � , �_ — 26 �� \ � �• � � � ] N . � 3 O — ' . � Q• � �' ` _ O ,,,_� — """ _'__ W 22 r �� ` ( (� `0 �. .;'� ..�---� 1 .O lL � � vr Z '•� _ 1 r� � � ! V m M� o N I � mo�. _ N � •� , ` 4. ' � N N �N � � � •� y� io 44' Q y ; � � , . �_ r . � � � . q' �_.,, �+, �� _ . . . . . �. . . �� • � . . • � +�� . � � . . . � � . .O t - . . �� L":t}' I'+� . � , � . . . �. � 'l th, � . ' � ' o_ < �f :'y� � �. • o i ' � . o, �d. �+ I � ) ' � �2 ' l / " °�, � � ! *� . �30:17' ' .a ' . • er _ ,_ �,:; .. � < , a - ." � N08"04'26'w ; _ i,�� . _ . . 272. 55' <' i � ' TOTA L . � � „ • � • � � , ��` � /J � ti < � �, C� �, � _ �o � , � �z:''�"� � a -� � � �u - p`�� o � � � 1 � AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION � (Void sixty (60) months from date of issuance) DATE: .3-3 I- q rI IlVIPROVEMENT PERNIIT #: l5�'2 TAX MAP #: i�� PARCEL #: C� OWNER/OWNER'S REPRESENTATIVE: C�s�.� e�" C'�✓r .Ir. LOCATION/ADDRESS: .�rl f�% `�`� �-� 13y2 , 3rd �uk �.� ��. . SUBDIVISION NAME: SECTION OR BLOCK: AUTHORIZATION FOR �z� e . AUTHORIZATION CONDITIONS LOT #: 1. The Wastewater system construction and installation must meet all of the conditions of the attached site plan and specifications as set forth in Improvements Pernut # 2�lS�Z . The construction and installation must also meet all applicable niles and laws. 2. No portion of the Wastewater system shall be covered or placed into use until inspected and approved by the Person County Health Department. 3. Any alterations in site or soil conditions (including structure locations) or modification in use, design wastewater flow, or wastewater characteristics as specified in the associated improvement pernut and application, may void this authorization and associated permits. 4. Conditions: �� i�h'1 l � �� 30 �� v N� ��,� o� � _ S� -�-�� '� c�e w�n , Person Requesting: �a� � ��s�� '��t ��m3S� r�l1 rh0 /� ��'l %%W�Q� L��Q{"� � , „