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��mprovements Permit (Established/Recorded Lot) I_ Reinspection of Existing System (Loan Closing)
Improvements Pernut (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
Repair/Replace existing Septic System
Permit for New Well
Existing Well
1. Permit requested by: .� 7. Dimensions or Proposed Structure:
owner/ rospect've owner/a ent: av� � Width: 3 6�
Aric�re.p� 1����a�.� g Depth: �`� /
ome Phone #:_
usiness Phone #:
Name and address of current owner: � l�_
�-e����� �- W\ C� 1-� _
Pronertv Descrintion: Lot size: Z���
. Tax Map#: l� a G
Parcel#: � a
Township• ► �e � ��
. Directions to property: State Road #& Road
ames, etc.
512-133
Number of occupants or people to be served:
8. What type (if any, additions, expansions, or
replacement is anticipate�i to the structure or facility
that this sewage disposal system is intended to serve?
9. Water supply ty pe:
private L� public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No ❑
If so, identify location:
10. Type of structure/facility: Proposed: L�Existing: ❑
Type of dwelling: � �
House: Mobile Home: ❑ Business: ❑
Type of busi ess:
Number of Employees:
Number of bedrooms: 3
Garbage Disposal? Yes ❑ No ❑
�IBasement? Yes ❑ No ❑ If so, # 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 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 the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the propert to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this a ication/s�all beco e v�qid and an ees paid forfeited.
c (l �
Signed Owner or AutHorize�t Agent
Permit:Issued L"I
Permit Denied,�❑/
Plat Observed l�
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I,/�� �IJl1r�►� �. -
- �.
/ Z- ".Z 1- �'!S� � •
�ncro►tss-srrL av.v..vnnox Axsn i <: ne�a 2<: nt�n a ;: axEa a::.
_ _ _ _ __ _
1. SLOPE (%) - S S S S
S /'�,,,,� �a PS PS PS �
l../ U U U
2. SO(L TEX7URE (12-36 IN.) S I- S S S
(SANDY, LOM1Y. CLAYEY, N07E 2:1 CLAY) S � � PS PS PS
U ' U U
3. SO[L STRUCTURE (12-36IN.) • S S S
(CLAYEY SOILS) S �,iJ,�� PS - PS PS
/7/� U U U
4. SO[L DEPfH (IN.) ' S S S
PS 3 ��� PS PS PS
ll U U
i. RESTRICi1VE HORIZANS (IN.) ` I S S S
(QviPERViOUS STRATA, ROCK) PS /v � PS PS PS
U � U U U
6. SOIL DRAINAGF/GROUNDWATER S S S
(EXTERNAL k INTERNAL) P � t v PS PS PS
U �v U U U
7. SOIL. PERMEABILITY S S S S
(PERCOLOAiiON RATE) PS �/L// PS PS PS
� ���` U U U
8. AVAILABLE SPACE S S S S
PS � )/ PS PS PS
U �� U U U
9. SIiECLASSIFICA770N(SEEBELOW)
SOiL SERIES
SSUITABLE PS-PROVISIONALLY SUR'ABLE U•UNSUITABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.) C:WNiPRO�DOCSWPPSEC.SMFINANCE.PC
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT ' '
'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 O �,r�/� /�; /�
Owner/Contractor SC -� -� �G I � Ci c� Date 1 Z--� /- ��"
Location/Address 5� �� �,�;P� J 3�-2 --h� Sn# /339 � S`�D S� ��
s.x.# /�3 9
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
�ir Lot Area �, �,� �C, Size of Tank �(��Q �GI ' s:
Mobile Home Size of Pump Tank N'i�
ness # of Bedrooms 3 Nitrification Line �(� �3 `
Max Depth Trenches�1A ''
Permits may be voided if site is
Well and Septic Layout by
Comments:
Date 5-� - � � Installed by�
Well Permit Paid WE L
Individual Semi-Public
Public Re lacement
Site Approved
Well Head Approved
Grouting Approved
Comments:
in
Approved by
SYSTEM SPECIFICATIONS
Required Slab {,�
Air Vent
Required Well Log
Well Tag
Date -�3 - Installed by � Approved by
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 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 ia the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
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❑PERSON COUNTY HEALTH DEPARTMENT
355A S. MADISON BLVD.
ROXBORO, NC 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant �o�j Qd�r�Q.l►'l�
Address �S3 �}acK �a ,��Yic,� County P�rsvJr
Collected By TS
Date Collected�6 —1� �d9 Time Collected �� `�J?
Source: l]�'Well ❑ Spring ❑ Well Tap � Other
� R�—s� c�
r5'No Charge � Charge
***�****�***************�******�***�*****�************�*****************
�*****�*********��**************��********�********�*****�****�*******�*
Rescclls
Present Absent
Total Coliform ❑ �
FecaUE. Coli. 0 �
,
Reported By t�`^� ,�' ��
Date � � l� `� 'I
Date:�%4� - 9� '
Owner: �
• � �Location/Directions:
Subdivision Nzrne:
Drilling Contractor: _
PERSON COUNTY ENVIRONMENTAL HEALTH
_ _ -- • WELL LOG •
��Co-'!�-'d�
SR#
Lot #
. WELL, CONSTRUC'T'ION
Distance from Nearest Property Line �v�- Distance from Source of
Pollution �( a �`' �
Total Dep.th: CY� Ft. Yield:� GPM Static Water Level �?.1r' Ft.
Water Bearing Zones: Depth /i � Ft.�Ft� F� Ft.
Casing: Depth: From U to_��Ft. Diameter. �% Inches
TYPE: Steel � Galvanizeci Steel �
If Steel, does owner approve: Yes No
Weight: Thickness:Tl�� Height Above Ground: / �I Inches
Drive Shoe: Yes ✓ No -
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" gi�'e r�ason:
Grout: Type: Neat SandJCement �� Concrete
Aruiular Space Width Inches
Water in A.nnular Space: Yes No
. _ . Method: ��a . __ ��sur� � Po��a � . . . _
Depth: Fr�m C� �o :�c� Ft.
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
. � DRILLING LOG
Fram I To
�ormation Descri�tion
oi G( ot YD i�. r -
I HEREB��RTI�THAT E ABO E INFORMAT'ION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDA.NCE WITH REGULATIONS SET
FORTH BY�THE PERS0�1 COUi�"I'Y HEALTH DEPARTMENT.
Signature of Contractor Date