A26 132' r"
� ���son County Health Department
� � Sewage System Improvements Permit
Date: F 7".� This Permit Void After 5 Years Permit # F N-/� �e„
Owner. —17 � ��t�� P o��� �S S�R# �'
I.ocation/Directions: r �Cf� � y�
SubdivisionNam�g.�� � � Lot#ti/,�--
Lot Size: �. r� r �� Type of Dwelling:
Water Supply: Private: P�blic: C mmunity:
Bedrooms:- Gazbage Disposal f
Basement Basement Fixture
INFORMATION CER'I'IFIED BY
Environmental Health Specialist: er '°e
REppIIZ: REEVALUATIO :
$ize of Septic Tank: �a �� gallons Size of Pump Tank:
Nitrification Line: ���3 � �_�%�
Depth of Stone: 12 inches
Maac Depth of Trenches:
Alternative System: Conv. Pump LPP Pump
Remarks:
-------------------------
Date Well Approved:
BY
Date Se` g S � te
BY
Contractor.
_ Well should be 100 f� from any sewer system
— Environmental Health Specialist
-I�--�=-�I3
_ Environmental Health Specialist
�ATE OF COMPLETION
---------------
Sewage System location, installation, 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 s�h 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 Deparunent before any portion of the installation is covered and put into use. If
the site plans or incended use change this pernut is subject to revocation.
(G.S. 130 A-335F) m
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I.ocation of sewage disposal sewage system sketched on back.
(OVER)
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EF,V I CES
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4– 5-94 1:5�F� 91955l74���
PEF° ,��� n��h T�' -�E��l�dl i��c�ITa 1 CN �
Re���n� �ar�����4� �{ealth Department
- 11V�11 Permit
Date• - 's Permit Vaid After Years
Owrrer: �'? a i�r.r �lvie �(� �i � SO a v�s SR�
Subdivision Name: �'/ �`� ��/� Lot #
DrilliDg COntracior:
W�LL CONSCRUCLLQi�I
Distastce from Nearest Properry L,ine -- — Dist�ce from Soarce af 1
Pol�uptaa _
Tatal Depth: Ft� Y9eld: —_GPM Stacc Water Level Ft.
WacerBea:ing7.�ones: Deptt� Ft. Fc.�Ft.
Casing: Depth: From V W FG Diameter.��_ Inches
TYPE: Steel „ ___ G�lvenized 5tee1 �
If 3tee1, daes ownet approve: N�
Weight: Thic3ctess: He3ght Above Gro�md: jnches
Drive Shoe: Xes __ No __��_�._ �
Were Problems £s�couttured in $etting the Casing7 Yes,��_____ Na__�„___
jf "yes" give re�5ori:
Grout: Type: Ncat 5a�ement _--- Concretc
,4ruzul�r Spxe Width l L. __ �i'►ches �
wat�r in Aimulsr space: Yes _— IYo
Mechad: Pum� r �'oured '� x
Depth: From � �-
Materials Used: Na. Begs Portl�d Centent Wrigh: of i ba$ ,�
lbs. �
If mixture (saY�d, gsave}, cuttings) - Ratio: � —
ID Platts: Yes � Na - -
4 x 4 slab Yes � No____,..�-_--
I HEREBY CERTIF1' THAT THE ABOVE INFORMATION T5 �CORRECT
'�1T�S W�LL WAS CONSTRUCTED. W ACCORDANCE Wt'T'H Gt31.A
FORTH BY THE PE�50N COLiNTY H�TF� �3EP�TME�T�
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A]v�D TfiAT =
'TIONS SET �•
f�ate Issued
Sas�ztar'tari s Sign�t�:re Dato Compleud
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,
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Si�te Evaluation Applic3tion Date:
Fee Collected YES � NO
\�'�,qa
g APPLICATION FOR IMPROVEMENTS PERHIT
1 �' -�'-�,��� �' �
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1. Permit requested by: owner/prospective ow •
agent:
Address:
Home Phone ��:
2. Name and address of current owner:
�:
�.1 �-�� �, �i�n S�c��' S I w
tsusiness rnone �f:
3. Property Description: Lot size: C'li�c'S
4. Tax map ��: To nship: ���1�� ���
Subdivision Name: � i vl�j'-��
5. Directions to pro er,1ty: /�tate Roa/�d �� &/ �R/� d Names, e
�� /�� fl n ,., �n.AA,� _ IY, l�. �. i .._ !t'�l /Pf'� n ,� � � �
Lot ��:
6. Permit requested for: New Installation: _,� Repair:
Additional Renovation re-using present system:
7. Number o£ occupants or people to be served:
8. Dimensions of Proposed Structure: Width:
Depth:
%� %''1�
�a l�� �.
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 property?
11,
community? spring?
If so, identify location:
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:
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 truS
and represent the maximum facilities to be placed on the property. I understand if
the site is altered or the intended use changes, e permit shall.become invalid. ,.
Permits are valid for 60 months from date of is e. rmis 'o is hereby granted to
enter the property for the evaluation. G.S. A-33 ()
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Signed�Owner or Authorizec� Agent
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Permit Issued
Permit Denied
Plat Observed
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�'ACTORS — SITE EVALUATION AREA 1 AREA 2 ARF,A 3 AREA 4
S S S
1. SLOPE (X) S PS PS �
U LT
2. S�IL TExTURE (12-36 in.) S �N,.,,,1 S ��,�,� S S
(Sands, loamy, clayey, PS ,, Q� P d� PS SD� 2:( PS�=
Note 2:1 clay) U -}�� 3 �" ���� U U
? SOIL STRUCTiTRE (12-36 i.n. ) S S
(Clayey soils) PS PS PS p�
4. SOIL DEPTH (in.)
5. RESTRICTIVE HORIZONS (in.;
(Zmpervious Strata. rock)
6. SOIL DRAINAGE/GROUNDWATER
(bcternal & Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
S
S
P
��
PS
S
PS
U
S
�
S
PS
U
�
�
U
5'
PS
�
�
PS
S
PS
PS
S
$. OTHER (specify) PS PS PS PS t
U U U [1
9. SITE CLASSIFICATION
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
RECOtgfEtlDATIONS / COMMEriTS :
SiTE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies,
c�et areas, fill areas, wells, water bodies, slope patterns, etc.)