A27 177, . . z
r ��erson �County Health Department �
Sewage System Improvements Permit
Date: � I- 9`� `I't►is Permit-Void-After�ears Permit # 1= y���Z
Owner: ��-E{',�o .� Ni • / E �t �,+� � SR# /35�3
Location/Directions ��
Subdivision Name: �� a 1�P �-- C' l� -� Lot #-�
Lot Size: -2 � c rr Type of Dwelling:
Water Supply: Private: Public: Community:
Bedrooms: __ ������'" arbage Disposal
Basement Base ent s
INFORMATION CERTIFIED B
Environmental Heal[h Specialist: er or rep se cive
REpAIR: REEV UATION:
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Size of Septic Tank: � gallons Size of Pump Tank:
Nitrification Line: _� �� �X 3 ,
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv Pump LPP Pump
Remarks: L r� � .p r� � o•��Tt3 �'rs-� e"�
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Date Well Approved: �� ``�`9� Well should be 100 f� from any sewer system
gy Environme tal Health Specialist
Date ag S te Approv : � - � � ' � �
gy Environmental Health Specialist
� � CATE OF COMPLETION
Contractor: � �-D-" � i-�
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Sewage System location, installation, and protection must meet state and local
regulations. Septic tank should be pumped out every 3 to 5 yeazs and shall be maintained
by owner in such manner as not to create a public health hazazd. Septic tank and
ni�sification 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.
(G.S.130 A-335F)
I.ocation of sewage disposal sewage system sketched on back.
(OVER)
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NOTE: Make sketch of i��lat- ion showing lot size and shape, location of house, septic tanks, privies, water
t �fipplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
a. at la ote location of water supplies on adjacent lots. �: � � /��
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Well Permit
Date• " � y � � Th
Owner.
Location/D'uections:
Subdivision Name:.
Drilling Contractor:
Void After 5 Ye�,ars L
� o ti /ti1 , ! e�:. s v e_ SR# /� % 3
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Lot #
Distance from Nearest Property Line Distance from Source of
Pollution �D _
Total Depth:�_ FG Yield:� GPM Static Water Level FG
Water Bearing Zones: Depth L�Ft.�Ft Ft Ft
Casing: Depth: Fmm�_to t 3 Z_ Ft. Diameter:��Inches
TYPE: Steel Galvanized Steel -�
If Steel, does owner approve: Yes � No
Weigh��� Thickness: Height Above Ground:�� Inches
Drive Shoe: Yes s No
Were Problems Encountered in Setting the Casing? Yes No��
If "yes" give reason:
Grout: Type: Neat �� Sand/Cement Concrete
Annulaz Space Width '�-- Inches
Water in Armulaz Space: Yes No -�—"
Method: Pumped Pressure Poured /
Depth: From O to 2� Ft
Materials Used: No. Bags Portland Cement� Weight of 1 bag�lbs.
If mixture (sand, gravel, cuttings) - Ratio: to
ID Plates: Yes r /No
4 x 4 slab Yes iNo
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT �
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET �
FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. ;�
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S' e of o actor Date
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arutanan's Signature Date Issued
Sanitarian s Signature Date Completed
Sketch well location on reverse side.
I�OT�: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
s�.�pplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be
l�cated at later date. Note location of water supplies on adjacent lots.
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Site Evaluation Application
Fee Collected YES
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Date: � � 1 ��
NO
APPLICATLOId FOR IMPROVEMENTS PERMIT
1. Permit requested by: owner�pr�spective owner:
agent:
Address: �—
Home Phone ��: 5��—�S�
2. Name and address of current owner:
3. Property Description: L�t size:
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(j� 300 %Zuxt3v�Zo �!C Z7S7 3
Business Phone �ir:
��4�vp M� KE'�F�
� . 8 2 AGIZ.ES
4. Tax map �i�: Township: o��vE N�L�
Subdivision Name: BEAVEfZ �(Z�� Lot ��:
5. Directions to property: State Road �� & Road Names, etc.
� t,J`� �'% '['u�tJ �.EFT o►J L.a+Jlr sTb�26 RD '
T�21J � A.T' SCl1ul.E�-S 1�01�1T J-r S'IN�E (�E?cT C.oT �
wd. yNF r2 us s
u �iJ 2 @ �EM/EiZ C,26�iL �
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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: L�
8. Dimensions of Proposed Structure: Width: �- $ Depth: / d
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? community? spring?
Other source? (Specify):
Are there any wells on adjoining property? � ES If so, identify location:
Lcrr � TN� R�GNT � 6�uE Duu3tF w�r�E)_ C �-a�r 33�
11, Type of structure or facility: Proposed: �/ Existing:
Type of dwelling: House: ��waF Mobile Home: ✓ Business:
Type of business: Nu ber of Employees:
Number of bedrooms: ¢ Garbage Disposal? Yes � ro
Basement? Yes No �/ If so, number of basement fixtures:
12. Clearly stake al]. 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)
� Sig er or Au, r zed Agent
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Permit Issued 1�
Permit Denied
Plat Observed ✓
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i�ACTORS - SITE EVALUATION AREA 1 AREA 2 AREA 3 AREA 4
S S S S
1. SLOPE (X) PS PS S.• PS �
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2. SGli. TEKTURE (12-36 in.)
(Sandy, Ioamy, clayey,
Note 2:1 clay)
? SOIL STRUCTIJR.E (12-36 i.n. )
(Clayey soils)
4. SOIL DEPTH (in.)
5. RESTRICTIVE HORIZONS (in.)
(Zmpervious Strata� rock)
6. SOIL DRAIDIAAGE/GROUNDWATER
(�cternal & Internal)
7. SOIL P�RMEABILITY
(Percolation Ratc)
PS
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$. OTHER (specify) P5 PS PS PS •
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9. SITE CLASSIFICATZ�JN � �
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Uasuitable
R ECOt�SEIZUATZONS / COMMENTS :
S.�TE CLASSIFZCATZON DIAGR1124 (Include: Soil areas, property lines. roads, streams, gullies.
Wet areas, fill areas, �aells. c�ater bodies, slope patterns, etc.)