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A27 176
.i �ite�aluation Application Fee Collected YES � � d I � 2°8�4 � �ce` � �� � � q- Ii(0 APPLICATIOId FOR IMPROVEMENTS� U� � d q � � ,� �-- a � g � Y�e�- 1. Permit requested by: ownerfprospective owner: agent: Address: p�i � � � �� a Date: `-� � � � � � ` .,. � HIT � � � , . (�,,,� , . „ _ z Home Phone ��• � .� Business Phone 4�: �lid oZ 2. Name and address of current owner: .��/�'�►"��U �'f�UY't1 G-- �L,t��S 3. Property Description: Lot size: �'�� 4. Tax map ��: 021�1��D ownship: �LL(l� �`�� Subdivision Name: �F'Cc.IJ�Y F��¢-� Lot 4�: 5. Directions to property: State Road �� & Road Names, etc. �l 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: I 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 su 1 rivate? V public? _ PP Y P Other source? (Specify): Are there any wells on adjoining property? 11, community? spring? If so, icientity tocaLion: Type of structure or facility: Proposed: l/ Ex'�} ting: Type of dwelling: House: Mobile Home: �� Business: Type of business: Number of E� oyees: Number of bedrooms: �arbage Disposal? Yes No Basement? Yes No If so, number of basement fixtures: 12. Clearly stake all. corners of the property and the corners of all proposed structures. 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 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) , �i� �/ . igned Owner or Authorizeri Age t H � r• t7 H w x m r 0 �+ m Permit I: Permit D� Plat Obs� i�ACTORS - SITE EVALUATION AREA 1 AREA 2 AREA 3 AREA 4 S S S 1. SLOPE (X) PS� D� PS PS PS � U U :.T 2. SGLI. TEXTURE <12-36 in. ) S S S S (Sandy, loamy, clayey, PS n �- PS PS PS Note 2:1 clay) �Th° U U U 3. SOIL STRiJCTURE (12-36 in. ) S S S S (Clayey soils) PS �� PS PS PS U U U S S S S � 4- SOIL DEPTH (i.n. ) ��S`���a� PS PS PS �t3� U U U 5. RESTRICTIVE HORIZONS (in.) S S S S (Impervious .Strata, rock) �S ,�Cr� PS PS PS i�� U U U 6. SOIL DRAIIdAAGE/GROUNDWATER S � S S S (External & Internal) PS j�,p �q PS PS PS i" U U U 7. SOIL PERMEABILZTY S S S S (Percolation Rate) � { -3,�L PS PS PS U U U S S S S g. OTHER (speci£y) PS PS PS PS � U U U U 9. SITE CLASSIFICATION �� (See below) SOIL SERIES S- Sui.table PS - Provisioaally Suitable U- Unsuitable R ECO2-II�SENDATIONS /COMMF�TS : S?:TE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, c�et areas. fill ,3reas, Wells. water bodies, slope patterns, etc.) q � -� . PERSON COUNTY HEALTH DEPARTIVIFNT WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERNIIT Tax Map #_� ,2 f'J Parcel # Zoning Township _ ��O�i V �_ ��l Owner/Contractor Location/Address Ca ►- ��-� .s� � J/Q,-s "i Subdivision Name _ y -�-� - N� - � i - ��" � �o� . `, �p' �� �% i \ � �J � 1-L�----i � 1(�` s�� _' �t'" S/D S.R.# Lot �J� / � �� , ,� � SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area Size of Tank Q�� �� S� Mobile Home Size of Pump Tank NI/a Business # of Bedrooms� Nitrification Line ����' Max Depth Trenches a �� �- Pernut Void after 60 months. Permit Void if not in compliance with zoning regulations. Pernuts may be voided if site is altered , i en ed u e ch ged. Well and Septic Layout by ,y q��j��,,,�� Comments: ; " Date Installed by Approved ;¢ WELL SYSTEM SPECIFICATIONS Slab Public Replacement Air Vent � Site Approved �� Required Well Lo� ./ Well Head Approved Well Tag ,/ Grouting Approved Comments: Date (Q Installed by '$�enneif Approved by This report is based in part on infortnation provided the homeowner or his/her representative in the application submitted for this pemiit The environmental health specialist is not responsible for false or misleading informaGon contained in the application The environmental health specialist is also not responsible for concealed rnnditions 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 wazrants that the septic tanlc system wil( continue to function satisfadorily in the future or that the water supply wiil remain potable. c:�amiprolpeimitsam Ol/95 rev.1.0 ORIGINAL �j j - �tT J FY i`-'Y '� `� .. ; v . �.` .. .. . � " . . � I � i�. �. , " _ - . . ... � 1 � ♦ ��� � T' i � ..'� �) .�.� �o � � -� ' S s� �i 1�� � M � � �tf��, rJ �..�,r k .�.:i L� 3�.+�. �s . 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