A26 135� >
P�rson County'Heal�h Department
�ewag� System Improvements Permit
Date: � I•Z'1�- q2This Permit Void After 5 ear�. Permit # �N ��� �
Owner: � *�. ��,�� �i-1 ��:�i SR# / 3 3 �
Location/Directions: '
Subdivision Name: N-- �'mn^ � p � t#_�,
Lot Size: /t S�l G r_�t s'ype of welli g:
Water Supply: Private: !/ Public: Community:
Bedrooms: 3 Garbage Disposal
Basement Basement F' rtm s �
INFORMATION CERTIFIED BY I �
Environmental Health Specialist: er o ��c�ci�e
REPAIR: REEV UATION:
Size of Septic Tank: _���Dl%� gallons Size of Pump Tank:
Nitrification Line: �(�Ca � X 3 �
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
-------------------------
Date Well Approved: Well should be 100 fG from any sewer system
BY Env r nmental Health Specialis[
Date S g S te Appmv : �� — �^��
By Environmental Health Specialist
..�E�tTIFTCATE OF COMPLETION
Conuactor. � � � �--��-�� `��
Sewage System location, installation, and protection must meet state and local
regulations. Septic tank should be pumped out every 3 to 5 years 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 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) R
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
NOTE: Make sketch of installation �1����n�g �t 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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� Pe�son County. Health Department �
;
Weil Permi� , �
Date• - '�j This Pennit Void A�'ter �3 Yj�s �� �
Owner•=��t�l, � `4�C2�12' c�- SR# 1��
Locadon/Directions:
Subdivision Name'. ' -� � r"
Drilling Contractor.�
Lot #
D'utance from Nea t Propaty+ Line�� Distsnce from Source of
Polludon D b c�s
Tatal Depth:� Ft Yeld: GPM Stadc Water L.evel �_FG
Water Bearing 7Anes: Depth � Ft Ft. FG �t.
Casing: Depth: From �_ to �.3 FG Diameter: L� Inches
TYPE: Steel Galvanized Steel ��
If Steel, does owner approve: Yes No
Weight:l,�_ Thiclrness• � Height Above Crround: _�� Inches
Drive Shce: Yes � No �
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason:
Grout: Type: Neat Sand/Cement `"� Concrete
Annular Space Width � Inches
Water ia Armular Space: Yes No_�
Method: Pumped Pressure Pouced�=
Depth: From �_ to FG
M Used:. . No. Bags Portland Cement �_ Weight of 1 bag
_ ���lbs.
If mix (sand. gtavel, cuttings) - Ratio: �-co �, _
ID Plates: Yes �" No
4 z 4 slab Yes ✓ No
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I HEREBY CER'TIFY THAT THE ABOVE WFORMATION IS CORRECf AND THAT �
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTTH REGULATIONS SET r;
FORTH BY THE PERSON COUNTY HEAL DEPARTMENT. �.
�10�,�' l�/', o,I�,� 11, �� %�
Date Issued
Sanitarian's Signanue Date Completed
Sketch well locatian on reverse side.
NOTE: 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 oi water supplies on adjacent lots.
(1) ^ (2) .,
Person County Health Department
Existing Sewage System Report For:
Requestee:
� Mobile Home Replacement
Addition
1 � � �
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, _ � _ �+ _•
Original Yermit Located
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Septic System Uesign r'or:
Itesidential Business
Home L'hone# ��J"" ����
Business#
`Pax Map# � ��v �
��L /l�ln r-E-�� -�'c�ll � Q�.
Other (specify)
# Bedrooms � # �mployees Other _
Uate lnstalled ��'" 1"�� Wa Ser supply ' cJ�
'Pype of System l �G�
Nitritication Line I����)
Tank Size
Certified Operator Required
N\�
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On site wasL-ewater disposal system showes no visually apparent
malfunction on �f � � � v
Yermission is granted to: � 0. 1� ���-�� � -
According to t
Comments:
attached site plan.
. �
Environmen�al Health ��C..
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Receipt .�� '
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Date
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Improvements Permit-(EstablishedlRecorded Lot) _. Reinspection of Existing System (Loan Closing)
I�ovements Permit (Unrecorded Lot) _. Repair/Replace existing Septic System
lmprovements Permit (Mobile Home Replace) ._ Permit for New Well
Improvements Permi[ (Addition) _ Replace Existing Well
: _ = Z = _ ' � `�'ater Saim�le to be Collecfec��
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` �B acteria _ Chemical Petroleum _ Pesticide _ Lead
1. Permit requested by: .
owner/prospective ownec
Address: • �d �
_� . 1 14
ome Phone #:.
usiness Phone
u�
7. Dimensions or Proposed Structure:
Width: ( �- — �7 D
V eS Depth:
`' �a 8. What type (if any, additions, expansions, or
'— replacement is anticipated to the structure or facility .
' C a that this sewage disposal system is intended to serve?
e
`� � � � o
. Name and addre�s of current o}�vner: 9. Water sup 1 type:
' � ; [ � (,Jv vd S _ private public ❑ community ❑ spring ❑
� Are any wells on adjoining property?Yes ❑ No �.
If so, identify location:
Description: Lot size:
Tax Map#:
Parcel#:
Township: e-
- .�
. Directions to property: Sta
iames,�tc.
S� 1333 �"o
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Road # & Road
S�2- )33 �
Number of occupants or people to be served:
10. Type of structure/facility: Proposed: ❑Existing: Q
Type of dwelling:
House: ❑ Mobile Home: Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �
Garbage Disposal? Yes ❑ No �
Basement? Yes ❑ No f so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pet'son 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 unders[and 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 [he 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.
or Authorized Agent
�rmit Issued ❑ Signature Date �r
i �.
ermit Denied ❑
lat Observed ❑
�' ..,c. '.:: �AcroRs-siiEEvn�Unno?+.. " � ..:.�. # , '��ty� '. . ., : �2 � , i+x�s r N�s ,, . $.: : <:
_ � � , ,..,.:>... ...,>.:. .,.. - <,.
,: . . .. :.... . .
1. SIAPE (%) S S S S
PS PS PS PS
U U U U
2 SOII.1'EC71JREp2•361N.) S S S S
(SANDY. LOAMY. CL\YEY. NOTE 2:1 CLAI� PS ' PS PS ps
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l. SO1L S77tUCTURE (12-161N.) S „ S S S
(QAYEY SOTLSi PS PS PS PS _
U ' U U U,
S S S S
3. SOILDEP7'ti(W.) PS ps ps PS
p U U U
3. RESTR]Ci]VE HORtZONS (iN.) S . S � ..- . _. S . : . - S •
(IMPERVIOUS SIRATA. AOCK) PS PS ' PS PS
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6. SOILDRAINAGFJGROUNDWATER S S S S
(DCCIILNAL & Q�(TFRNAL) PS PS PS PS
U � U U U
7. SOII,PERMEABIISiY S � S S S
(PERCOIAA770N RAT� PS ' : PS PS PS
._ _ U U U U
E. AVAILABLE SPACE S S . S S.
PS PS PS PS
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9. SiI'ECLASSh7GTI0N(SEEBEL01�ry
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SOIL SEkIES . , .
S-SUITADLE PS-PROV1510NALLY SUiIABI.E U-UNSUITAHLE
RECOMMENDATI ONS/COMMENTS :
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope pattems, CtC.� C:Nh1fPR01DOCSAPPSEC.ST1 FWANCEPC
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I � DONNIE R. SAUNDERS
� D.6.188, P. b07
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II SNEILA R. CLARK '
i I D.B. 207, P. 42� w
31.80 � IF
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TOTAL
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D.B. 204, P. 266
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