A27 164'
Site Eva�uation Application
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Fee Collected YES '�
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1. Permit requested by
Address: �D)
Home Phone ��: 5�'19-3a�1�' Business Phone ��:
2. Name and address of current owner: �eeG� I�eIC�. h y=I
Date: 5���-/� �~ `
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APPLICATIOH FOR IMPROVEMENT� PIItMIT
owner/prospective owner: �
_ agent: _
3. Property Description: L�t size: 1'�p �CY�
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4. Tax map ��: Aa7-lc�� Township: ��,�Ve �' �'
Subdivision Name: �c�rer CreelC. Lot ��:
19
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S. DirectiQns to property: State Road �� & Road Names, etc./1
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6. Permit requested for: New Installation: ✓ Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served: �
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8. Dimensions of Proposed Structure: Width: c��D � 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.
11,
Water supply private? ✓ public? community? spring?
Other source? (Specify):
Are there any wells on adjoining property? If so, identify location:
Type of structure or facility: Proposed: � Existing:
Type of dwelling: House: Mobile Home: ✓ Business: _
Type of business: Number of Employees:
Number of bedrooms: �_ Garbage Disposal? Yes ro �"
Basement? Yes No v If so, number of basement fixtures:
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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 m�ximum facilities to be placed on the property. I understand if
the site is altered or the intended use changes, the permit shall become invalid.
Permits are valid for 60 months from date of issue. Permission is hereby granted to
enter the property for the evaluation. G.S. 130A-335(F)
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Signed ner or Authorized Agent
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Permit Issued
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Permit Denied
Plat Observed
i�ACTORS - SITE EVALUATION AREA 1 AREA 2 ARFA 3 AREA 4
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1. SLOPE (�) P O-�j��o PS PS PS
2. SGIL TEXTURE <i2-36 in.)
(Sandy, loamy, clayey,
Note 2:1 clay)
? SOIL STRUCTLTRE (12-36 in.)
(ciayey So�is>
4 . SOIL DEPTH (in. )
5. RESTRICTIVE HORIZONS (in.
(Im{�ervious Strata, rock)
. SOIL DRAI2�IAGE/GROUNDWATER
(bcternal & Internal)
. SOIL P�RMFABILZTY
(Percolation Rate)
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9. SITE CLASSIFICATZON n s
(See below) ��
SOIL SERIES
S- Suitable PS - Provisi.oaally Suitable U- Unsuitable
R.ECO2�4fENDATZONS / CO2•R IF�TS :
S.�.TE CLASSIFICATION �IAGRAH (Include: Soil areas, property lines, roads, streams, gulZies.
Wet areas, fill areas, c�ells, c�ater bodies, slope patterns, ete.)
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' PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERNIIT
Tax Map # �� � Parcel # / � � � . �
Owner/Contractor
Locationl�4ddress
A`O�f 3
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Subdivision Name Y Lot#_ f�
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SI� l-- i�Yy; Vir� Q-o -�
i3 H3
SFD
Business
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Sx `�'AGE 5Y5'TEM SPECIFICATIONS
�,c�t �rca 3 Size of Tank_�
Nlobile Home Size of Pump Tank
# of Bedroorns � I'�itrification Line
Ma� Depth Trenches.
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Permit Void after 60 montr�s. Permit Void if n�t in compliance with zoning regulations.
Permits may be voided if sitE is alter i en ed use changed.
Well and Septic Layout by
Comments: ,�
Date
Installed by � t� '�-�W � � Approved
WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab ✓s
Public Replacement Air Vent f
Site Approved ✓ Required Well Lo�
Well Head Approved Well Tag
Grouting Approved
Comments:
Date � a1 9S Installed by �n� Approved by,
This report is based in part on infonnation provided the homeowner or his/her representative in the application submitted for this pemut The "
environtnental health specialist is not responsible for false or misleading infortnation contained in the application. The environmental healilt specialist
is also not responsible for concealed conditions on the propercy or for statements in this repoR that may have resulted from false or misleading
statements provided to him in the application. Neither Person County nor the environmental health specialist wazrants that the septic tanlc system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�pemutsam Ol/95 rev.1.0
ORIGINAL
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Horold N. Winsteod
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Jun-27-95 08:46A PERSON COUNTY HEALTH O P.02
PT;RSOI� COU�ITY F,NV1 RON^1EhT'AI. HT;ALTH
SJ1?i,L I,(JG
��itC: � - � /- �t�
Qwner: _�Q-� S° .�. . - � SK�� L s� �
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Loc;ation/D�recUons: �z ��.�_ 52� /�.�. � j��±�, �,,��/� �,�'�.� _
�uh�:vi�,i�n'�11me: /,�,�a� ��J ----. ,.� i.ut ��...._.._.__ _._.
Drilling Cantrac;tax: _�,�.Q. .._. .. . _ —_ --- - f2..— — —
W� L�ONSTRU InN +�� — � �
Distance fm�il Ncarr.st 1'ropc;rty Linc _ D'sstar��c. t�rc�ll� Sourcc ot�
I'ollution
Tot3a 17ep,th:,.,��"� � Ft. Yie1d: /`5 GpM Stat�c Water Level �t.
Wat�r Bcat�ing Loncs: Depth f3� Ft, i5s �t. Ft. Ft.
�:asing; Dcpth: From �,,,to �� Ft. I)iametcr: �% Inches
_w____.
TYPE; Stcel G�lvartii.ecl Ste�l ,
If Stce�, docs ovvnct a `
PF�+'�ve: Yes No
---______
Weight: � 3 Thickncss: /� sr Hci��t Abc�ve Ground� �� Inchcs
Drivc Shoc: Ycs„ ✓ No
W�re �'rob3�ms Encountcred in Setting t�e Casing? Ye� -- Nti�
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'c.s �;i�; � r�.as:��:
(it011i: T�: r(Cat ✓ S�c�/C�i»c:nE C.'oncrclC T
A,nnular Spacc Wadth � _ lnches '
Water in Aru�tular Spacc: Ycs ` Nc, ,i
. Method: pumpc:d� Pressure � our' �d v
I�cpth: Fr�m D to �, v Ft �
Matcrials Uset�: No. Bags Portland Cem�r,t____� ti�l�i�.�-,� r�� Z b3�,� Lhs.
If mixttuc (sanci, gravel, ctittin�s) - Rati�: ��
ID Pl�tcs: Yes ✓ �o ^ .-" +" _� `-
4 x 4 sYab Yes_ ,� No �
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DRILI,INC� I,OC;
D� th —
�'r�m To , Formation Descri tipn
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I H�k�BY CER7'ZFY THAT THE t�RUVE �N�'n�M�'rjpN 1S COKRLC"i� aNv �I'HA'I'
T��S WEL�, WAS CnNSTRUCTED TN �CCORI�r'�Nc:'E V��i"1'H R�GUL,� ��Ir�NS SET
FORTH �y.7'���; p�KSt�.ti t_ ��UN'I'�' HEALTH ULPAR'I'MEN"f .
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