A27 196� .- - z
.Person �County Health Department �
- -Se�age System Improvements Permit
Date: �� - This Permit Void After 5 Years Permit #
Owner: V-� �.1 �� CA An �� `�- �P `r� a� i�' SR# 3
Location/Directions: (' ,_ : ,� � ' . �
- ^ - -
s�ba���s�on �van,e: �Si�c hI � n d CYeQ.k' L� � v�1 Lot #!��
Lot Size: ,� _� r% Q C YPS Type of Dwelling:
Water Supply: Private: %' Public: Community:
Bedrooms: �_ Garbage Disposal itlb
Basement Basement Fixtures �
INFORMATION CERTIFIED BY �
Environmental Health Specialist: wner or resentative
REPAIR: REEVALUATION:
-------------------------
Size of Septic Tank: �i `i gallons Size of Pump Tank:
Nitrification Line: J��[�_,;� 3 �
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 Environmental Health Specialist
Date Sewage System Approved:
BY Environmental Health Specialist
CERTIFICATE OF COMPLETION , ,.�
Contractor. �
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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 years and shall be maintained
by owner in such manner as � not to create a public health hazazd. Septic tank and
ni.rification line must be inspected and approved by._a member of the Person Cpunty
Health Deparunent before any portion of the installation is covered and put into use. If
the site plans or intended use change this pemut is subject to revocation.
(G:S. 130 A-335F) `
L.ocauon of sewage disposal sewage system sketched on back.
(OVER) � .
N01'E: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supglies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots.
(1�� (2)
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�- .E�aluation Application
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� Fee Collected YES �
d �°�` �6os
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1. Permit requested by:
Address:
Home Phone �� :
Date: � N
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2d0
APPLICATIOId FOR IMPROVEMENTS PIIiMIT
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awner/�rospective owner:
agent:
2. Name and address of current owrier:
3.
4.
tsusiness„rnone �i:
Property Description: Lot size: .�%r/ c� �. �� C�-f/Ih
Tax map ��: •To nship: �
Subdivision Name: L Lot ��:
5. Directions to prope ty: State Road �� & Road Name e
��-sI i, � _ �J� ���a- � �SA2_ «a �7' �
6. Permit requested for: New Installation: v Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served:
L/
8. Dimensions of Proposed Structure: Width: Depth:
a
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? _
Other source? (Specify):
Are there„any wells on adjoining property?
11,
community? _ spring?
If so, identify location:
Type of structure or facility�oposed: � Existing:
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:
12. Clearly stake a17. corners of the property and the corners of all proposed structures.
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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 hereb granted to
enter the property for the evaluation. G.S. 1' A 335(F)
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Signed Owner or Authorize� Agent
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Permit Issu�c-'d � � . w
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Permit Denied .
Plat Observed
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i�ACTORS - SITE EVALUATION AREA 1 AREA 2 ARF.A 3 ARF_A 4
l. SLOPE (�)
2 . SGIi. TEXTURE (i2-36 in. )
(Sandy, Ioamy, clayey,
Note 2:1 clay)
3. SOIL STRUCTURE (12-36 i.n.)
(ciayey So�is)
4. SOIL DEPTH (in.)
S. RESTRICTIVE HORIZONS (in.)
(Impervious Strata, rock)
. SOIL DRAINAGE/GROUNDWATER
(bcternal & Internal)
. SOIL PERMFABILITY
(Percolation Rate)
g. OTHER (specify)
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9. ' SITE CLASSIFICATI�JN � �� , (
(See below) U
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECOr44ENDATIONS / COMMENTS :
S:tTE CLASSIFZCATZON :�IAGRAM (Include: Soil areas, property lines, roads, streams, gull.ies,
Wet areas. fill areas� c�ells, water bodies, slope patterns, etc.)
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A 001 046
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
Tax Map # %� a � ^ Parcel #
Zoning � �� Township 1'
Owner/Contractor �'� ,'��,� s� ��: �n �Ycc�. Date — —
Location/Address H��F' �
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Subdivision Na
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Lot# ,
SEWAGE SYSTEM SPECIFICATIONS
Lot Area��'�� Size of Tahk
Mobile Home t/ Size of Pump Tank '
# of Bedrooms�_ Nitrification Line
Max Depth Trenches.
Pernut Void after 60 months. Permit Void if not in compliance with zoning regulations.
Pernuts may be voided if site is altered or in ed us changed.
Well and Septic Layout by
Comments:
Date
Installed by !�/� y�F ��:clt�stN✓ Approved by
_ 1 .► n O O ,/_� q_q �1
WELL SYSTEM SPECIFICATIONS
3ividual_�Semi-Public Required Slab
iblic Rep ement Air Vent
te Approved Required Well Loo
ell Head Approved Well Tag �,/
-outing Approved
Comments:
Date q �7 �W'7 �stalled by
Approved by.
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This repoR is based in part on infocmation provided the homeowner or his/hec representative in the application submitted for this penniE The
rnvironmental health specialist is not responsible for false or misleading infocmation contained in the application. The environmecnal health specialist
is also not raponsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading
statanrnts provided to him in the application Neither Person County nor Qie environmenlal hcallh specialist warrants that the scptic tnnk system w���
continue to function satisfadorily in the future or that the water supply will remain potnble: c:4unipro�pem�itsam O1/95 rev.1.0
• P�IZSON COIIN7'Y IiNV:I:IZONP;;;N7'l�I, I1J,ALTII , � t�t��'`. '�
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Date: - 3 � �
Owner: I�, �� L l e.t��- _.� -_ SR# - � ,�':���;
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Location/Directions: �c��_/��,�---� � �-.r r-�-s L�-��tjd � . Y,
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�ub:.'�vision Name: �
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Drilling ConCrac[or: — __ ---- ----- - -__ #
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'�7�1'L'f -- �/�%.�_ / � ---� r�� /Z `� ty''��
WEI.,( ,_ CC)NSTRUCT[ON � � T'
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� Distance from Nearest Prope�-ty Liric__� S—��_ llis�ance from Source of ' .. �;,�
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Pollution_T� , ,,; s
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Total Dep.th: Fc. Yicld:� a GPM Static Water Level -`��
YVater�B�earing Zones: Depth �-o f _ �t _ �Ft, ;
Casing: Depth: From � Ft.� Ft. ,�t. "��'
' TYPE: ---�---_ °—._ .-� � --I_ t• Di amc tcr: � ` � Inches `;ti `
Steel - �.
� G.ilv��nizcd Stec] v �� . . �
Zf Steel, does o ��
wncr approv�:. Ycti jVo ;� r&,
' Weight:�_ Thickness: . . � ,,
'Abovc `
� Drive S ---�-�He�ght Ground:— ,����hes,� s-�� �-
hoe: Yes_ N�� � • � ,x � �ar� � .;
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Were �roblems Encpunterccl in Sc�tinb the Casing? Yes �� � No ~
Ii " es" ' -`-- ;�:r ,.
y grve�reason: .. �
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. Grout: Type: Neat . ` "�'}"'� �
, Sa�id/Ccmen[ � Coricrete :� :�,y �
A.nnular. Spacc Wieltli �3 Inchcs •
Water in ,A,nnular S acc: � -'� '''`
p Ycs No ✓ ,�. n..
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, . . Metho.d: Ptun c, 1'rc:;succ I'ourc:cl � . �`�" �
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Dcpth: From--� ---- __�-�i Ft. r . . ,' `
tc� �
Materials Usecl: No. Babs Portl�ind Cc � `" '��
ment_� Weis}-it of .l ba lbs:� <n•�: �`;
If mixture (sand, gravcl; ct�ttin�s) - Itatio: a-- to �� �'� `; a�:
.,, . ID Plates: Yes � No . , ,< .
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4 x 4 slab Yes —�LNo_ ,y;ti �
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D[:1 I;I.,I NG L(?Ct a
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Fram — -- ---- . ��-� ,. .
To Formation Descri tion , 1` �'
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� Z HEREBX CER`ITFY THAT TI-IE A,I30VE 1NFORMATION IS CORRECT .�'�
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T�S WELL WAS CONSTRUCTEll 1N ACCORDANCE WITH `�D THA�T4 �
- REGULAT'IONS SET�,� '`
F4RTH BY•THE PERSON COUNZ'X I-ILALTH DEPARTMENT. �
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