A27 166� �.
APPLICATION FOR IHPRO�TEMENT PERMIT
�
I � L�
DATE: (/ 'I/ �/
�
l. Permit requested by: � ✓+r Home Phone�
Address: Business Phone
2. Name and address of current owner: J �',-,,,,,,i,�, �)i
3. Property Description: Lot size /i,�.�Gl GrP S Dimensions:
Front Left Right Rear
4. Tax map No. Township: Block No. ot No. c
5. Directions to property: State Road No. b Road Names, etc. ,���'
� A
6. Permit requested for: New Installation Repaired
Additional Renovation re-using present system
7. Number of occupants of people served
8. Dimensions of Proposed Structure: Width Depth
9. What t}�pe.(if any) additions, expansions, or�replace.,�ent is a.��icipated
te the structure or facility that this sewage disposal sys�.em is intend
to serve?
10. Type of water supply: Well yes no: Zf no, name source of water
supply: 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�siness
Type of business Number of Employees_
Number of Bedrboms Number of automatic appliances
Basement Number of basement fixtures
12. Clearly stake all carners of the property snd the corners�of all proposed
structures.
I herebp make application to the Person County Health Department for
a site evaluation or existing spstem evaluation for the on-site sewage
disposal spstem for the above described property. I agree that the conte.
of this application are true and represent the maximum facilities to be
placed on the propertp. I understand if the site is altered or the in-
tended use changes, the permit shall become invalid. Permits are valid
for 60 months from date of issee. Permission is herebp granted to enter
the property for the evaluation. G.S. 130�335(F) ,
�
�. _
Agent
z
a
3
�
- SITE EVALUATION
`�LOPE (X)
�-iOIL--TGXTURE (12-36 in. )
�Sandy, Ioamy, clayey,
Note 2:I. clay)
�SOIL STRUCTURE (12-36 i.n.)
(Clayey soils) �
�OIL DEPTEi (in. )
RESTRICTIVE HORIZONS (in.)
;Im{�ervious Strata, rock)
�OIL DRAIIQAGE/GROUNDWATER
(bcternal & Internal) -
�OIL PERMF�IBILITY
�Percolation Rate)
, � � � �
� �
���� � '
S
PS
u
S
�{
!a
S
PS
S
PS
S
�
S
�
S
AREA 1
AREA 2
S
U
S
� ��.
S
�
S
S
PS
U
S
S
ii
�
�
_� �
AREA 4
S
PS
u
S
�
S
PS
U
S
PS
U
s
PS
U
S
PS
U
S
PS
U
S
]THER (specify) ps ps PS ps I
' U U U U
SZTE CLASSIFICATION -
(See below) '
�OIL SERIES --�
S- Suitable PS - Provisionally Suitabie U- Unsuitable
.��NDATIONS/COMMENTS.
, CLASSIFICATION DIAGRAM (Include: Soil areas, property lines. roads, streams, gullies,
���t areas, fill.areas, wells, water bodies, slope patterns, etc.)
� �Y
��erson County Health Department
Sewage System Improvements Permit
Date: �� This P�rmit Void After Years Permit # -�
Owner: '�� � SR#
Location/Directions: N. Lz , L�.. S'. d '�� l
.�a � C..�.�¢. �.t. n t� � ,� 2 r .. .r . _
Subdivision N e• F� Lot #
Lot Size: '� - Type of Dwelling:
Water Supply: vate:� Public: Community:
Bedrooms: �_ Garbage Disposal
Basement Basemen[ Fixtures
INFORMA'I�O�T�D BY _ I -- � .�. �,.s ,-�'
REPAIR:`-� -•• -
'ALUATION:
Size of Septic Tank: �_ gallons Size of Pump Tank:
Nitrification Line: � /') f 7,�� � �
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks:
-------------------------
Date Well Approved: Well should be 100 ft� from any sewer system
BY Sanitarian
Date Sewage System roved: l�-zS-9/
BY � Sanitarian
CERTIHiCATE OF COMPLETION ` ,�
Contractor. ,3�,..,�.:� N� N� «_ .� �
------------------------- �
�
Sewage System location, installation, and protection must meet state and lceal �
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)
Location of sewage disposal sewage system sketched on back.
(OVER) ,
tL
NO'I'E: Make sketch o! installation showing lot size and shape, location oi house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
�&'t later date. Note location of water supplies on adjacent lots.
�(1) , (2)
Person County Health Departmer� �
"'� Well Permit �
Date:�.� This
Owner.
L.ocaaon/Directions:
Subdivision Name:
Drilling Contractor.
Void Aftex 3 Years
m F{'
sx# 3 3 � j�
I
Lot #
, 'd
Distance fro Nearest erty Line_���s Distance from Source of �'
Pollution
c�
Total Depth: Z�F� Yield: �(�GPM Static Water I.evel "�Ft. ~
Water Bearing Zones: Depth � FG F� FG Fc
Casing: Depth: From 0 to �_ F� Diameter. �i Inchcs
7'YPE: Steel Galvanized Steel �--
ff Steel, d owner approve: Yes No
Weigh� � Thiclrness: ���Above Ground: �_�Inches
Drive Shce: Yes �� No
Were Problems Encotmtered in Setting the Casing? Yes No `
ff "ycs" givc reason• ►�d ,
Grout Type: Neat Sand/Cement Concrete �'
Annulaz Space Width �? Inches
Water in Annular Space: Yes No �--
Method: Pumped ' Pressure Poured L._
Depth From _� to .�_�
��aLc Used: No. Bags Portland Cement � Weight of 1 bag
h�� Ibs.
If m ture (sand, gravel, cuttings) - Ratio: � to �_
�D Plates: Yes � No ,.ti
4 z 4 slab Yes No �
De th �
F To Formation Descri tion
Z
� �
I HEREBY CER'CIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SEf
FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT.
� .
Sketch well location on reverse side.
��.i�J!�l�.�% ���/�l�P ln�l/�9/
Sazutanans Sig a rc Date Issued
�� ,8. � /2-2-9/
Sanitarians Signa e Date Completed -
; �/