A26 141� �-�� z
ers�^h-,County Health Department �
Sewage �ystem improvements Permit
Date: �l'3� This Permit Void After 5 Years Permit #���°�� °�
Owner: -J o�e �n D, o e r� e r- SR#
Locadon/Directions: � � ,� � � —y )
Subdivision Name: �I / n�j'PI> >/,�/ Lot #� ��
Lot Size: —� �� G �j' P S Type of Dwelling:
Water Supply: Private: —� Public: Community:
Bedrooms: � Garbage Disposal � �
Basement Basement Fi ture
INFORMATION CERTIFIED BY �
Environmental Health Specialist: er or �c�u�e
REPAIR: REEVALUATION:
Size of Septic Tank: �� allons Size of Pump Tank:
Nitrifica[ion Line: 6� jC � �
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks:
Date Well Approved:
BY
Date S � ge y �
BY
Contractor:
Well should be 100 ft from any sewer systerr
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_ Environmental Health Spec�alist
ATE OF COMPLETION
Sewage System location, installation, and protection must meet state and local
regulauons. Septic tank should be pumped out every 3 to 5 yeazs 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 Department before any portion of the installation is covered and put into use. If
the site plans or intended use change this pemut is subject to revocation: �
(G.S.130 A-335F) _
Location of sewage disposal sewage system sketched on back. �
(OVER) , _ _
NOTE
.
: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
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�'ocu� �t �sc�:r(�`� 1�tuY► �s
. �ersc� �=ount� Health Department
� � WeII Permit
Date: T'his Permit Void After 5 Years
Own�r ��1-, C%, Q1 c� P rr, e r SR# � 3 3 y
Location/Directions: -
� v� �/v0 ���✓�S �
Subdivision Name: .�qt� No /o
Drilling Contractor: , l ^+
WELL CONSTRUCTION
Distance from Nearest Properry Line Distance fmm Source of
Pollutio� � � j� �
Total D th: L Nv FG Yield: GPM Static Water Level F�
Water Bearing Zones: De��� Ft. FG FG
Casing: Depth: From to Ft. Diameter Inches
TYPE: Steel Galvanized Steel
If Steel, does owner approve �No
Weight Thickness:� Height Above Ground: Inches
Drive Shoe: Yes No
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason:
Grout: Type: Neat aAEj/Cement Concrete
Annulaz Space Width �� Inches
Water in Annular Space: Yes No
Method: Pumped Pressure Poured '�
Depth: From �to F�
Materials Used: No. Bags Portland Cement Weight of 1 bag_lbs.
ff mixture (sand, grave , cuttings) - Ratio: to
ID Plates: Yes No
4 x 4 slab Yes �� No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY THE PERSON COUNTY I-1�?�T}I.DEPQ�TMENT. �
Date
9- 3�—�r
issu�a
Sanitarian's Signature Date Completed
Sketch well location on reverse side.
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NO�'E: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
'- su�lies, 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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(1) ' (2)
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. . •. - . �
, Site Evaluation Application
Fee Collected YF.S /
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Date: I ���'"� -T
AYPLICATJON FOR IHPROVEHENTS PFdiHIT
1. Permit requested by: owner,'�ruspective owner:
', agent:
Address: �
Home Phone �� :
-0�4a Business Phone��i:
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2. Name and address of current owner:
3. Property Descriptiqri: Lot size: o�{. /�C/L�r
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'PN �. 13Co
q.✓.D Gov�v �2s�
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9i9- 9� 9-
TF' 9- A G F�7�'.i
4. Tax ma ��: Townshi QL/U� �//LL
Subdivision Name: P• Lot �'�: ��'T��N/N6 L�� 7
A/.�/T2C-CE :SU.I���d/.s/a.d _,�r�,,.ti-2� �su.00i✓,�s.A
S. Directions to property: State Road �� & Road.Names, etc.
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l�F%-/ �-- �-U/ /J ,U//Ctc/GT /Y�K�J.� /-KU/// �C�WT/i�/t N/�i /«'u/y._✓!"ryFL
6. Permit requested,for: New Installation: Y Repair:
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Additional Renovation re-using present system:
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7. Number of occupants or people to be served: �
8. Dimensions of Proposed Structure: Width: � lp �/D �� Depth: a�/
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10.
What �ype (if any) additions, expansions, or replacement is'anticipated to the struc-
ture or facility that this sewage disposal system is�:intended to serve?
i � � �
Water supply private? public? �� community? spring?
,: .
Other, source?'(Specify):
_ _.__ .
Are there any wells on adjoining property? If so,.identify location:
11, Type of structure or facility: Proposed: � ;_. !Existing:
Type of dwelling: House: /� Mobile Home:",' � Business:
Type�of'business: -- ,'Y ---Number of Employees:
Num�er of bedrooms: � Garbage Disposal� 'YeS- ro � `"
Basement? Yes No �/ If so, number of basempnt fixtures: iy/�g `�'
.
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12. Clearly stake all corners of the property and the corners of all proposed structures.
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- �^�I �hereby make appLication to-�th'e'-Person .County .He�1,th:,.Department for a site _._.__
evaluation or existing system.evaluation for the on-site sewage disposal'system �for`'
the-above-described- groperty. ---I-.. agree-.that.. thev;:cont.ents ,.of,..this application aie ?true
� ` lities.__to._be,�-pla_ced �n;_:.the.� property. I understand' if
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�the� siteeisnal'teredaor-mthef intend'ed: use:�_cNanges:, .the~permit. shall become invalid.
�Permits��are~ valid-for-�60• months--�from date -of _is.sue. ..�Permission is hereby grantedi�to
enter-�the property for the.,evaluation G.S. 130A 335(F).
'1 .' 1 1 �i., • i•. ". . .. . .. . � . '. . ' ' A .'Y ' ' .. . .
, . i . _ i . s. , ' . � .. .T , i. . . . • .
. Signed Owner or Auth rize� Agent
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Permit Issued
Permit Denied
Plat Observed
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i�ACTORS - SITE EVALUATION ' AREA 1. AREA' Z"{ ' AREA 3 �' AREA 4
::,a , .: ; . S S ,. , . t ; ,;, S S
1. SLOPE (X) PS D�- ��o PS PS PS
' U `'� U LT
2. SOiL TEXTURE (i2-36 i.n. ) S S S r
(Sandy , Ioamy, .clayey, P � �vXt � PS ' PS PS
Note 2:l clay) U � U U U
�3 . SOIL STRUCTiTFtE (12=36 i.n. ) S S � S S
(Clayey soils) P S�� PS� ` PS PS
, _. .
U � . .,.. .._ U U
; ti.._. . _ S ( ess �4� S s S __
4. ;50IL DEPTH (in. ) P 3� ,, PS . PS PS
iJ ' _. U U
,5. RESTR�CTIVE;HORIZONS (i.n.) S- S � S S
� � .r j�, „ : i w;, � . . � �
(Im{�ervious Strata. rock) ��o►� pS ' PS PS
U U U ..
6. SOIL DRAINAGE/GROUNDWATER .. _ S S S S
'..�.(bcternai & �ntez�al) PS . �0,, /1+.n� PS� ' ` ` PS PS .
.._ ..».....� .._ ; f...4GLs:, U .,1�, . ... U .. ... , . . U U' .
, . ..., . ... .... . �
7. _SOIL"rPERMEABILITY - . z�� .S -..- '. S S
, ;: n
(Percolation Ratc)�'. ; . , pS �: ��� . :PS f , , ' PS PS"
.._ _. U:
�___.:. _ .__.__.._.�. _ __ .. � ,_. . U
) :s �S, .:S-, , S S
$ �_ OTHER (specify) PS ' ,PS ' �PS PS •
.
,. ; , U _ _ , U_; , U
; � U
,.. ,
9 • :. SITE3CI.ASSIFICATIpAI : •, : - , ,` . ,
: -. , ..� .J � ` � .
�(See,below).,; �;
` SOIL� SERZ£S-���-� +
. .�., . _. ,, . , .. . .
# . E, S� �-��Suitable - � , PS .-,.Provisionally:-Suitable _ U. - Unsuitable
RFCO�NDATIONS/COMMENTS•
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S:�:TE CLASSIFICATION DIAGRAM (Include: Soi1 areas, property lines, roads, streams. gulZies.
Wet areas. fill areas, wells,�aater bodies, slope patterns, etc.) ,