A27 182� ' " � z
_ Person County Health Department �
Sewage System Improvements Permit
Date:��'This Permit Void After 5� y(ears Permit #��{ 23%y
Owner: �YG,q� j��c��Cih SR# y/?�
Location/Directions:
Subdivision Name: _ 1���'� V 21� LYP�fs_ Lot #
Lot Size: Type of Dwelling:
Water Supply: Private: Public: Community:
Bedrooms: ��— Garbage Disposal
Basement Basement s
INFORMATION CERTIFTED B�
Environmental Health Specialist: o er or r�u�e
REPAIR: REEVAL ATIO :
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Size of Septic Tank: �noo gall�on`s, Siz �of Pump Tank:
Nitrification Line: �_�_X �
Depth of Stone: 12 inches
� Depth of Trenches:
Alternauve Syste : Conv. Pumpn LPP Pump.��/
Remazks: _ �.P✓ �J'�� ✓� � � � .�6'/ �' ,fiP � �v�
_����it__�}�—_—_—_.�—_—_._----
Date Well Approved: Well should be 100 ft� from any sewer system
By Environmental Health Specialist
Date a te Approv L1 " ��- '�'t y
gy ' Environmental Health Specialist
CERTINiCATE OF COMPLETION
Contractor: � 1—¢.n.e � ► �
Sewage System location, installation, and protection must meet state and local
reguladons. 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
niirification 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)
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
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NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
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� Person County�F-lealth Department �
Well Permit �
Date: -'�`j Thi�P.ermi Void�r 5 Y ,�
Owner. SR# —��� �
Location/Directions: _ �
Subdivision Name: ,
Drilling Contractor:
Lot #
Distance from Nearest Property Line Distance fmm Source of
Pollution
Total Depth: 305 FG Yield: / GPM Static Water Level Ft.
Water Bearing Zones: Depth Ft. FG Ft Pt
Casing: Depth: Fmm��to�i_Ft. Diameter:�Inches
TYPE: Steel Galvanized Steel �—
If Steel, does owner approve: Yes No
Weight Thickness: � Height Above Ground:1_� Inches
Drive Shoe: Yes �— No
Were Problems Encountered in Setting the Casing? Yes No�
If "yes" give reason:
Grout: Type: Neat ✓ Sand/Cement Concrete
Annular Space Width � Inches
Water in Armular Space: Yes No ✓
Method: Pumped Pressure Poured_�
Depth: From to FG
Materials Used: No. Bags Portland Cement�_ Weight of 1 bag�lbs.
If mixture (sand, gravel, cuttings) - Ratio: to
ID Plates: Yes_�L No
4 x 4 slab Yes � No
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT �
THIS WELL WAS CONSTRUCfED IN ACCORDANCE WITH REGULATIONS SET �
FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. ,�
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i an e o o ractor Date
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'tanan nature Date Issued
Sanitariati s Signature Date Completed
Sketch well location on reverse side.
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 at later date. Note location of water sunnlies on adiacent lots_
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Site Evaluation Application
Fee Collected YES� /
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Date: � �) � I
APPLICATTOId FOR IMPROVEMENTS PERHIT
1. Permit requested by: awner/prospective owner:
agent:
Address:
Home Phone �� :
2. Name and address of current owner:
3.
4.
S.
Business Phone �r`:
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Property Description: Lot size: %.6 �fi,Qj�j
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Tax map 4�: �� Township:
Subdivision Name: � t/{�2 'L �FI'C 1y Lot �i:
Directigns to proper,j�' State Road �� & oad , etc.
/ rs.v�s �-f�-�2L� /�--D .
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:
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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? ''( L- S If so, identify location:
Type of structure or facility: Proposed: � - E isting:
Type of dwelling: House: Mobile Home: � Business: _
Type of business: Number of Employees:
Number of bedrooms: Garbage Disposal? Yes No
Basement? Yes No 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 hereby make application to the Person County Health Department for a site
evaluation or existin� 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 ranted to
enter the property for the evaluation. G.S. 13 A-335(F)
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Signed Owner r Authorize� l+gent
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Permit Issued V
Permit Denied
Plat Observed �'
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l?ACTORS - SITE EVALUATION AREA 1 AREA 2 ARF.A 3 AR.EA 4
1. SLOPE (X)
2. SGIL TEXTURE (i2-36 in.)
(Sandy, Ioamy, clayey,
Note 2:1 clay)
3. SOIL STRIICTLTRE (12-36 in.
(Clayey soils)
4. SOIL DEPTH (in.)
5. RESTRICTZVE HORIZONS (i.n.)
(Im{�ervious Strata� rock)
6. SOIL DRAZrIAGE/GROUNDWATER
IA
(bcternal & Internal)
7. SOIL PERMEABILITY
(Percolation Ratc)
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g. OTHER (specify) PS PS PS PS �
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g. SITE CLASSIFICATZ�JN �
(See below)
SOIL SERIES
S- Suitable PS - Provisi.onally Suitable U- Unsuitable
R ECOt�R�I�IDATZONS / COt�41F�ITS :
S�:TE CLASSIFICATION �LAGRAH (Include: Soil areas, property lines. roads, streams, gullies,
Wet areas, fill areas. c�ells, water bodies, sZope patterns, etc.)