A26 126�r- ,;., z
Person County Health Department �
Sew�ge System Improvements Permit
Date: "�-�fhis Permit Void After 5 Years Permit # �
Owner: � � ��Q �P ���� � SR# y% ��
I,ocation/Directions:
Subdivision Name: /l7' � Lot #
Lot Size: Type of Dwelling:
Water Supply: Private: Public: Community:
Bedrooms: �— Garbage Dispo �
Basement Basement F' es ��
INFORMATION CERTIFIED BY �
Environmental Health SnecialisC L�%'�, °� 'r `�`ese"
REPAIR: REEV�UATION: � "`" " " " _ _ _
--------+-� - ----------
Size of Septic Tank: ///G�t/ gallons Size of Pum Tank:
Nitrification Line: �—���� � � �e � � �
Depth of Stone: 12 inches
Max Depth of Trenches: �
Altemative System: Conv. Pump LPP Pump
Remarks: �, � A _ ,! _��—�1 ��' -
Date Well Appmved: Well should be 100 ft from any sewer system
By Environmental Health Specialist
Date Sewage System Approved:
gy Environmental Health Specialist
CERTIFICATE OF COMPLETION
Contractor.
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Sewage Sys[em 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
nitrification line must be inspected and approved by a member of the Person County
Health Depaztment before any portion of the installation is covered and put into use. If
the site plans or intendeci use ehange this pernut is subject to revocation.
(G.S.130 A-335F) -_
I.ocation of sewage disposal sewage system sketched on back.
(OVER)
NOT'E: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, 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.
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Site Evaluation Application
F'ee Coilected YES �
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1. Permit requested by:
Address:
Home Phone ��:
Date: �-��- qy
NO
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APPLICATION FOR IMPROVEMENTS PERHIT
mer rus ctive o /
� agent: �
Business Phone �r`:
2. Name and address of current owner:
3. Property Description: Lot size: ,�,`7��( �vCV� S
) 1 r /
4. Tax map ��: �� I�'� Q�ownship: o� ✓� �� lr
Subdivision Name: fl,�� �j'<[ Lot ��:
5. Dir C� io�s/ to pr�o� ty: State Road �� & Road Names, etc.
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6. Permit requested for: New Installation: � 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?
Other source? (Specify):
Are there any wells on adjoining propert
11, Type of structure or facility:
Type of dwelling: House: _
Type of business:
Number of bedrooms:
Basement? Yes No
community?
If so, ident
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spring?
ifv location:
Proposed: ✓ Existing:
Mobile Home: Business: _
Number of Employees:
Garbage Disposal? 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 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 m�ximum facilities to be placed on prope ty. I understand if
the site is altered or the intended use changes, th ermit sh ll becom invalid.
Permits are valid for 60 months from date of issu Permi�si i� b granted to
enter the property for the evaluation. G.S. 13 335(F)
Si�ied Ow�er or Authorized l�gent
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Permit Issued
Permit Denied
Plat Observed
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i�ACTORS - SITE EVALUATION AREA 1 AREA 2 �REE� 3 AREA 4
1. SLOPE (X)
2. SOZL TEXTURE (i2-36 in.)
(Sandy, Ioamy, clayey,
Note 2:1 clay)
3 SOIL STRUCTITRE (12-36 i.n. )
(Clayey soils)
4 . SOIL DEPTH (�n. )
5. RESTRICTIVE HORIZONS (in.
(Impervious Strata, rock)
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SOIL DRAIIQAGE/GROUNDWATER
(�cternal & Internal)
SOIL PERMF.ABILITY
(Percolation Rate)
g . OTHER (specify)
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g. SITE CLASSIFICATION ��� / J� �(' ��
(See below) U ��
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
REC0�4�EAtDATIONS / COP4fIIdTS :
S1TE CLHSSIFZCATION DIAGRAM (Includet Soil areas, property lines, roads, streams, gullies,
wet areas, fill areas, wells, aater bodies, sZope patterns, etc.) I
A 1433
PERSON COUNTY HEALTH DEPARTMENT
r-- �' WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT
Tax Map # � 2(p �'arcel,# � 7,( r�
Zoning Township �I � J V �-{ �' � � ��-9 �
Owner/Contractor w � � � � � � Da .
Location/Address
S.R.#
Subdivision Name �-� �n i- r-�� Lot#
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SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area 2. (o C Size of Tank
SFD �/ Mobile Home Size of Pump Tank
Business # of Bedrooms�_ Nitrification Line �-) Oa`�l� �
Ma�c Depth Trenches � �"
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or intended use changed. •
Well and Septic L�out by �_ OY� (J Q,a�.A-�_•1��.�(.�
Date 1 I a3- � 7� Installed by ��l�"r►vn -C�,(.�Q.Csi. Ap�it-oved t
d6 l6-�
` WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab �
Public Replacement Air Vent ��
Site Approved Required Well Lo�'
Well Head Approved W 11 T�g
Grouting Approved - � - �
Comments:
Installed by
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This report is based in part on information provided the homeowner or his/her representative in the application sUbmitted for this permit The
environmental health specialist is not responsible for false or misleading infotmation contained in the application. The environmental health specialist
is also not responsible for concealed conditions on the propetty 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 satisfadorily in the future or that the water supply will remain potable. c:�amipro�pemrit.sam O 1/95 rev.1.0
ORIGINAL
. ' P�RSON COUNTY ENVIRONMENTAL H�ALTH
� WE��• �LOG ,
Date: f (0 4 .. � � SR# - .
o , tl�31�1t
wner.
Location%Directions: � .
Subdivision Name: � �
L�t � __
Drilling Contractor: �a
WEL
Distancc from Ncarest Property Linc_. -_
D�stancc from Source of
Pollution � 2„ GpM Static Water Level F�
Total Dep.th: F� Yield: . �t.
p Ft. Fc. Ft.i
Water Bearing Zones: De th ��Ft. Diameter: / Tnches
Casing: Depth: From�_to �
fiYPE: Steel � Galvanized Steel -
If Steel, does owner approve: Y�s NO- Inches
Weight: �� '1'hickness: • Height Above Ground:______
Drivc Shoe: Ycs No • -----
Were Problems Encountercd in SettinS the C��g� Yes � No______
;, "ycs" givc rcasor�: Coricrete
Gr�ut: Type: Neat _ Sand/Cement -
A,nnular. Space Width 1�___�ches
Water in Annular Spacc: Yes No,_____
Method: Fumped � Pressure__.____ �oured ��.._.
Depth: From _O _ to O Ft.
Materia]s Used: No. Bags Ponland Cement,.,. Weight of .1 bag___�lbs.
to �
xf mixture (sand, gravel; cuttings) • Ratio: - .
7D Y'latcs: Ycs '� No _ ,.
d�r d clah Yes ✓-_� NO '
I HEREBY CERTIFY THAT THE ABOVE TNFORMA CE WITH REGULA ONS SET
THIS WELL W�1S CONSTRUCTED IN ACCORDAN
FORTH BY�THE PERSON CO'UNZ'Y HEALTH DEPARTMEN'r.
' 11 Ia q
Signaruc of Contract � Dat�