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Permit (Established/Recorded Lot) I_ Reinspection of Existing System (Loan Closing)
Improvements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
Repair/Replace existing Septic System
Permit for New Well
_ Replace Existing Well
1. Permit requested by:
�wner/nrosnective owni
ome Phone #: S 9} - R/9�
usiness Phone #: �``'/9 ' ��Qq �"`" �9� "'`� ��
and address of
7. Dimensions or Proposed Structure:
Width: O
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
owner: � o-��0 9. Water supply type:
/ /Y% � �..l� �.Ce.PrJ private C�public ❑ community ❑ spring ❑
�ire any wells on adjoining property?Yes 0'No ❑
If so, identify location:
. Property Description: Lot size: 3. �/ �c'
. Tax Map#: A a 7- 8 A � 1� 7� a c�
Parcel#: a'7 '� �� A e r e s)
Townshin:- ��Ii cier � >l _
Directions to property: State Road #& Road
ames, etc.
� ,v-. ,,., e , .a.�,c � A-�.�P c�o iNL. 9— �}'J , �//
Number of occunants or neople to be served:
10. Type of structure/facility: Proposed: ❑Existing: ❑
Type of dwelling:
House: �iMobile Home: ❑ Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �_
Garbage Disposal? Yes ❑ No C�'
Basement? Yes ❑ No B'If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pers0tl COunty Health Dep�rtment for a site 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. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
Signed Owner or ��khorized Agent
Permit Issued. ❑
Permit�Denied ❑
Plat Observed ❑
Signature Date
4 . •� .
L, ,
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1 FACSORS-SiCEEYALUATION i:: ;: . ARPA1 ;;; ;: AREA2 :` >: AREh3 '.'.AREA4 ::. .
_ _ _.
1. SLOPE ( k) S S S
PS" O �� PS PS PS
O D U U
2. SO[L7'EXNRE(12-36INJ S S S
(SANDY, LOAMY, CLAYEY, NOTE 2:1 CLAY) � � PS PS PS
U U U U
3. SOIL S7RUCTURE (12-361N.) S S S
(CLAYEY SOILS) PS S�� PS PS PS
U U U
4. SO[L DEPI'H (IN.) S S S
;'� � PS PS PS
U ✓�� U U U
5. RESTRICi7VE HORiZONS (IN.) S S S S
(IMPERVIOUS STRATA, ROCK) PS ��;O PS - PS PS
� U U U
6. SOIL DRAINAG&GROUNDWA7ER S S S
(EXTERNAL & INTERNAL) PS � � PS � PS PS
�o�es U U U
7. SOiL PERMEABILITY S S S
(PERCOLOATION RATE) P ���p�p pS PS PS
U •�Avl'�' U U U
8. AVAILABLE SPACE S � S S
PS PS PS PS
U U U
9. SITECLASSIFICATION(SEEBELOW) �
SOIL SERIES
S-SUIiABLE PS-PROVISIONALLY SUI'fABLE U-UNSUI7'ABLE
RECOMMENDATIONS/COMMENTS:
STTE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.) C:WMIPRO�DOCSIAPPSEC.SMFINANCE.PC
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A0*74
°- ' PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCAT �ON IlV�ROVEMENT PERNIIT �~
Tax Map # a r% Parcel # S � S
Zoning Township C7 /�✓e �%i�/J
Owner/Contractor i ri � /��a�S/ v � v Date �/O -�%�
Location/Address � /t�#' v ►- P,- � F
S.R.# ,305 �/�06
Subdivision Name
�o'_ ,��,ecP
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Lot#
0
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SEWAGE SYST�M SPECIFICATIONS U '
Repair Lot Area��, �S"��S Size of Tank /��� C,;{LLa •, s,
SFD �/ Mobile Home Size of Pump Tank n/y� _
Business # of Bedrooms�_ Nitrification Line Q�Q(7 O X�_
Max Depth Trenches � ���
Pernut Void after 60 months. Permit Void if not in compliance with zoning regulations. F;�i�
Permits may be voided if site is alter or i tend d use hanged. D�:� �
Well and Septic Layout by �r�"`�`�
Comments: ___ _
Date 5/i 7!� L Installed by � c�� � e Co,c Approved by.
, . .
Individual
Public
Site Approved.
Well Head
Grou g Appr
Comments:
WELL SYSTEM SPECIFICATIONS
Semi-Public Required Slab ..
Zeplac nt Air Vent _ _
Required Well �
- We�a
Date Installed by � IM{'�fApproved by� �/ V I/�
"Ilvs report is based in part on information provided the homeowner or t� r representative in the application submitted for this pennit The
environmental health specialisl is not responsible for false or misleading infotmation contained in the application The envuonmental health specialist
is also not responsible for concealed conditions 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 Pe[son County nor the endvonmental health specialist wazrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�pemutsam O1/95 rev.1.0
ORIGINAL
V
PERSON COUNTY HEALTH DEPA�tTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
�► a-� -�1
Name of Owner or Tenant ��.-�- -� �o °�y� �"``�^�� -r�Q-9"'r"'
Address ��t�1S �i��s,�-, (�' County���S3J-�
�xb�rv �lC
Collected By �
Date Collected c}�-- 3- \5 -o�- Time Collected /c� � a 5
Source: �Well ❑ Spring O Other
Location: �House Tap
pNo Charge �harge
i
pWell Tap ❑ Other
�C..i�-ty.a,�
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*�**�*****��**�***�*��*��******�**������*�*�****�****��***���******�**���*�***
Total Coliform
FecaVE. Coli
Results
Present Absent
❑ C�
❑ I�
Reported By � � mT
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