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ments Permit (Established/Recorded Lot) I_ Reinspection of Existing System (Loan Closing)
Improvements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) _ Permit for New Well
Improvements Permit (Addition) _. Replace Existing Well
V�ater samrle to be Coilecte�•
:::
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_ Bacteria Chemical _ Petroleum _ Pesticide _. Lead
1. Permit requested by:
owner/prospective own�
ome Phone #: c�'�5�a 6� �
usiness Phone #:
Name and address of current owner:
Descrintion: Lot size:
Tax Map#:
Parcel#:
Township: ��.11 �/1; %-i.��
Directions to property: State Road #& Road
mes, etc.
Number of occupants or people to be served:
. Dimensions or Proposed Structure:
Vidth:
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
9. Water supply type:
private �public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No�
If so, identify location:
10. Type of structure/facility: Proposed: QExisting: ❑
Type of dwelling: �,�
House: ❑ Mobile Home: Ly"Business: ❑
Type of business:
I�iumber of Employees:
Number of bedrooms: �
Garbage Disposal? Yes ❑ No �j
Basement? Yes ❑ No [�1 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 Depai'tment 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 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.
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Signed Owner or Authorized Agent
Permit Issued ❑
Permit Denied ❑
Plat Observed ❑
Signature Date -3 �6-��
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1. SLOPE (%) . .. . . ..../� . . ...... S S S
PS � O L-/'� PS PS PS
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2. SOIL TEX7URE � 12-36 IN.) S S S
(SANDY, LOAMY, CLAYEY. NO'iE 2:1 CLAn PS "� PS PS PS
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3. SOIL S77tUCNRE (12-36IN.) S S S S
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S. SOiL DEP7'F! (Rd.) S S S
PS �/� �� PS PS PS
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3. RESTRICf[VEHORIZONS(IN.) S S S
(IMPERVIOUS STRATA, ROCK) S /�'v U U U
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6. :;OII. DRAINAGE/GROUNOWATER S S S
(EXTERNAL R QJiERNAL) �I v PS PS PS
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1. SOII, PERMFABILtTY S S S
(PERCOLAA7ION RA7'E� PS �� �J�, PS PS PS
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8. AVAILABLESPACE S S S S
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9. SLiECLASS6�7CA710N(SEEBELOW) �
SO(L SERIES
SSUITABLE PS-PROVISIONALLY SUITAOLE 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:NMfPR01DOCSIAPPSEC.SMFINANCE.PC
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2 NOTES: 1) Boundary description taken from survey by
F' Phillip J. Hall, RLS, dated April 1974.
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-� 2) The purpose of this map is to show the location
of a proposed mobile home site as staked in the
field and requested by the Person County Health
Department.
Property of:
GLENN C. & MURIEL C. DILLON
907 Brooks Dairy Road
Olive Hill Township, Person County
North Carolina
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JOHN V. DILLONt RLS
4504 Tenby Drive
Greensboro, N. C.
1 APPROVED BY:
SCALE: `" = ZQd'
DATE: �j-��j-9GD
DRAWN BY ,J V Cl
REVISED
DRAW ING HUMBER
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PERSON COUNTY HEALTH DEPARTMENT
Y.. � � WELL AND SEWAGE SITE, LOCATION IlVIl'ROVEMENT PERMIT �._
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shail be issued until Authorization for waste water system construction
. has been issued.
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Tax Map #_� � � Parcel #_
Zoning Township
Owner/Contractor � /� r��.,T C , /.� i
Location/Address .�rJ /�i ,�, Sn t� / �
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Subdivision a�l me
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S.R.��
Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area � G✓P • Size of Tank � �t
SFD Mobile Home ,/ Size of Pump Tank a���
Business # of Bedrooms� Nitrification Line o�� l �C 3�
Max Depth Trenches ..2 � t� - . -
Permits may be voided if site is
Well and Septic Layout by
Comments:
Date
Installed by,
use g�anged.
Approved by
ell Permit Paid ❑ WELL SYSTEM SPECIFICATIONS
3ividual Semi-Public Required Sla _
�blic Re 1 Air en
te Approved Required W og
ell H pprov Well T �
�outing Approved _
Comments:
Date
This report is based in part on info�fmation 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 in the future or that the water supply will remain potable.
c:\amipro\permit.sam Ol/95 rev.l.l
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AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
' (Void sixty (60) months from date of issuance) � �
DATE:� 7 —%, �o IMPROVEMENT PERMIT #:
TAX MAP #: � PARCEL #: / ��
OWNER/OWNER'SREPRESENTATIVE: V-12�?n �� ,D��%�on!
LOCATION/ADDRESS:
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SUBDIVISION NAlV�:
SECTION OR BLOCK:
��'vr� �� o�
LOT #:
AUTHORIZATION FOR CO�TRiJC'�ION I�SUED BY:
AUTHORIZATION CONDITIONS
1. The Wastewater system construction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Permit #�� The
construction and installation must also meet all applicable rules and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any alterations in site or soil conditions (including structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authorization and associated permits.
4. Conditions:
Person Requesting: