A26 119. .. � � z
Person County Heaith Department �
S�wage System Improvements Permit
Date: 3" �O ��Z'This Permit Vo After 5 Years Permit #
-� i k�- + Q��' 'S�" SR# % "� �
Owner•
Lacation/Directions: �
Subdivision N�me: �'� i C1 '�V �[� Lot #. .�
Lot Size: �•����� Type of Dwelling: {�, �s�
Water Supply: Private• Public: Community:
Bedrooms: '�_ Garbage Disposal �
Basement Basement Fix �
INFORMA D BY �
$Billi8t18I1: - er or repmsa�tative
REPAIIt: REEVALUATION:
-------------------------
Size of Septic Tank: _�� ��U(1 �X 3Size of Pump Tank:
Nitrification Line:
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pamp
Remarks: �. < n t n � i.
Date Well Approved: � v a P�93 Well should be 100 ft from any sewer system
BY Sanitarian
Date Se e y Approv d: ��%' �'2' S�
BY Sanitarian
TIFTCATE OF COMPLETION ,.�
Contractor. _ - _;_� ,�,� �
------------------------- �-�,
Sewage System location, installation, and protection must meet state and local �
regulations. Septic tank should be pumped out every 3 to 5 yeus and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and 3
nitrification line must be inspected and approved by a member of the Person Cow►ry
Health Departrnent 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) _ �
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Location of sewage disposal sewage system sketched on back. c�
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(OVER) �
_te Evaluation Application
Fee Collected YES ✓
�;�,`� � S 35
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1. Permit requested by:
Address: �
Home Phone ��:
Date : � ' �o - �a
NO �� � a�
�� �
APPLICATION FOR IMPROVEMENTS PIItMIT
owner/prospective owner: � L
. agent: �
i 79/.
2. Name and address of current owner:
3. Property Description: Lot size:
tsusiness rnone �f:
1 (/
4. Tax map ��: Tow ship: �� I%e �(
Subdivision Name: r�`� �/�Q•z
5. Directions to property: State Road �� & Road Names, etc.
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Lot ��: '�
6. Permit requested for: New Installation: V Repair:
Additional Renovation 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? Q If so, identify location:.:
11,
Type of structure or facility• roposed: 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:
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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,s;ite_;:.
evaluation or existing system evaluation for the on-site sewage,disposal�syste,m for �
the above�described property. I agree that the contents of this application�are true
_--_
and represent the maximum facilities to be placed on' he""property ���':" I�-understand �if _{,
`� the'site is :'altered=or'�:the"�-in�ended use changes','`t permit"shall`:become"'""invalid':`:"'`"
, ;._.,.. . _. , �
`PerIIiits are valid for 60 months from date of iss :" Per issio is h reby granted..to
� 4 R�. ` enter -the property for��the . evaluation. G. S: �- -335 F) --�
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i'�:�rmit Issued �
�rmit Denied
lat Observed _�
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�`�.ICTORS - SITE EVALUATION AREA 1 AREA 2 AREA 3 AR.EA 4
:i_ . SLOPE (X)
% SGZL TEXTURE (i2-36 in. )
(Sandy, loamy, clayey,
Note 2:I clay)
. SOIL STRUCTURE (12-36 in.
(Clayey soi.Is) �
. SOIL DEPTH (in.) ��
. RESTRICTIVE HORIZONS (in.)
(Impervious Strata, rock)
, SOIL DRAIIZAGE/GROUNDWATER
(F�cternal � Internal)
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. SOIL PERMEABILITY
(Percolation Rate)
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?. SITE CLASSIFICATION
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable •..0 - Unsuitable
; �ECOt�R�AIDATIONS/CO2�41ETITS:
I�LTE CLASSZFZCATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies,
wet areas, fill areas, wells, water bodies, slope patterns, etc.) '
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