A27 119� �� z
� Persc�n County Health Department �
Sewage System Improvements Permit
Date: �� - �This Permit Void After 5 Years Permit #� l��a �� 3
Owner: /� v,�,,_,✓:_ ��E�-�eL�'J ��l' '�`�
Location/Directions ���
„ . . � � o s� � . . .
Subdivision Name: � Lot # '/
Lot Size: —� ����C v�" S Type f Dwelling:
Water Supply: Private: ✓ Public: Community:
Bedrooms: �_ Gazbage Disposal
Basement Basement Fi s
INFORMATION CERTIFIED BY
Environmental Health Specialist: � res�' ' e
REPAIR: REEVALUATION:
Size of Septic Tank: ���� gallons Size of Pump Tank:
Nitrification Linc: %J�'�i? � ,T_�'i �,�-.
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemadve System: Conv. Pump LPP Pump--�—
Remarks: / � , I 2.. � L l % t�-
-------------------------
Date Well Approved:
BY
Date ag 6y te
BY
Well should be 100 f� from any sewer system
Environmental Health Specialist
. Environmental Health Specialist
� c; x 1 ir1�ATE OF COMPLETION ,�
Contractor. � �n � . r t'� �
------------------------- �
b
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 hazazd. 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 permit is subject to revocation. �
1
(G.S. 130 A-335F)
L.ocation of sewage disposal sewage system sketched on back.
(OVER) .
r�
L
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
_ w . /1
�c,t� 1��`i►a sTATE t�o�n6s
I��rson County Health Department
������ Well Permit
Date:1Q,/ 7'T—% 7 This ermit Void Af , 5 Years i/�
Owner. �� Y�� YC� Y�Wh �.��-�#'
Locati��ti�DirecUons: ,A, ,
Subdivision Name:
Drilling,Contractor:
�
�
� .S% „ 'd
���- �
Distance from Nearest Property Line Distance from Source of
Pollution�
Total Depth:�« FG Yield:�. GPM Static Water Level Ft.
Water Bearing Zones: De th t. Ft FG� ►i- PG
Casing: Depth: From�_fo Ft. Diamete •�": Inches
TYPE: Steel Galvanized Steel �
If Steel, does owner approve�No
WeighG 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 SD� Cement Concrete
Annulaz Space Width C� Inches
Water in Annular Space: Yes No
Method: Pumped u e Poured ��
Depth: Fmm �—to FG
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
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCfED IN ACCORDANCE W1TH R ULATIONS SET
FORTH BY THE PERSON COUNTY H T EP ENT.
` il B Qy
Si e of Contractor ate
lOr// /
Sanitarian s i ature Date Issued
Sanitarian's Signature Date Completed
Sketch well location on reverse side.
'b
�
�
�
�d
z
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
�upplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be
.located at l�;ter da.e. Note location of water supplies on adjacent lots.
o, a
' � (1) . .. �z� , ,
� � �
_ \, . � �
, I
�. . rM � . . .,., �
�^ y
Y� � Cy ,
s ,
.�
. . I l In '
,
�� . ,, -� � _
S1te E�aluation Application
✓
Fee Collected YES
�
it� �3��3�.�`i
�R��
1. Permit requested by:
Address:
Home Phone �� :
Date: ��14 —� I
NO
APPLICATION FOIt IMPROVEMENTS PIItHIT
owner/ rospective owner:
agent:
2. Name and address of current owner
Bus ine s s Phone �� :
���, Cn
3. Property Description: Lot size: ���t3� fV� S
/ /l
4. Tax map ��: ��.7 To nship: 0 i 1/{ 1
Subdivision Name: �1� �,,., a Lot ��:
S. Directions to property: State Road �� & Road Names, etc.
6. Permit requested for: New Installation: � Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served:
8. Dimensions of Proposed Structure: Width: Depth:
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, Type of structure or facility:
Type of dwelling: House:
Type of business:
Number of bedrooms:
Basement? Yes No
community?
z
H
�
H
w
�
spring? I�
I�
If so, identify location:
Proposed: i/ Existing:
Mobile Home: Business:
Number of Employees: .
Garbage Disposal? Yes No
If so, number of basement fixtures:
12. Clearly stake all corners of the property and the corners of all proposed structures.i
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 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 rmit hall become 'nvalid.
Permits are valid for 60 months from date of issu Perm's ion is er granted to
enter the property for the evaluation. G.S. 13 - 35(F) '
Sign 0 r or Authorizeci Agent
r
0
r+
m
Permit Issued
Permit Denied
Plat Obseryed
�
r , �
��ACTORS - SITE EVALUATION AREA 1 AREA 2 ARFA 3 AREA 4
S
1. SLOPE (X) PS PS PS PS
U � U � i,T
2 . SOZL TEXT[7RE (12-36 i.n. ) � � . - � S ,
(Sandy , Ioamy, clayey, PS % ' PS ,� ^�,�. PS � �
Note 2-1 cla ) �-� �� U r/ U
• y -�
3 SOIL STRUCT[TRE (12-36 in. ) S � S S c��
(Clayey soils) P PS PS PS
U �: �
S S +
4. SOIL DEPTH (in.) PS PS S PS
U � U
5. RESTRICTIVE HORIZONS (in.) S S S
(Ia�ervious Strata, rock) PS P PS PS
U U U
6. SOIL DRAIrIAGE/GROUNDWATER S S S
(�cternal & Internal) PS , PS S PS �
U
7. SOIL PERMEABILITY S S S S
(Percolation Ra.te) PS PS PS ps
U U U U
S S S S
g. OTHER (specify) PS PS pS pS `
U U U U
9. SITE CLASSIFICATION ` � �
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable __
R ECOt-II�NDATIONS / CO2 R4EDITS :
S7TE CLASSIFICATIOt1 DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies,
Wet areas, fill areas, wells, water badies, slope patterns, etc.)