A27 21„,•�_�r.,.
Person County Health Department
�wa e System Improvements Permit
This Permit Void After 3 Y � I- �e
^ l� l✓�(-`,�S��ISR#��,—�—
Subdivision Name: � ” ` " ' ' " � ' �� #
Lot Size: 7 r r Type of Dwelling: �..�
Water Supply: 'vate: PuUlic:
Semi Private: ff not Private Tax Map#
Parcel # of Water Supply or Name of
Supplier#
Bedrooms:—� Garbage Disposal
Basement Basement Fixtiue
INFORMAT`�� TI�IED BY
SaI11I1I1311: � /'^� ��j#� owner or repms tativ
REPAIR.� � ' f � � REEVALUATION:
------ — 1
, — ----- --
Size of Septic Tank: gallons
Nitri6cation Line: �+��'
Depth of Stone: 12 inches (� ,
Max Depth of Trenches: `� ' � '
OPERATIONAL PERMTT: yes no
Remarks: -'" -._
Date Well Approved• Well should be 100 fG from any sewer system
BY Sanitarian ,P
Date Se e s m ppro+ • /„_ 7-' �%
BY s 'tarian
z
CER CA OF C MPLETION �
Contractor. _� � e �" � ���,� �
------------------------ �
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 hazard.
Septic tanlc and nitrificaLion line must be inspected and approved by a member of
the Person County Health Departmen[ before any portion of the installation is
covered and put into use.
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
:
1
_
� 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 supplies on adjacent lots.
(1) �Z�
._ -
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # �a � Parcel # �
Zoning ,_,, Tqwnshin ��i� V � - ��lJ
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Owner/Contractor /VI CtVl � �l �3�•� �oo/ Date �I- /_S- y�
Location/Address ��
.R.# �
Subdivision Name Lot#
Layout
As Insta(led
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r� �(�' G�'l,�er- � oF G` "L�
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Q nr�/J'�y S / Pvf/i �P /� � �-+'f 2 � � � � .
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SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area
SFD Mobile Home
Business # of Bedrooms�_
Permit Void after 60 months. Permit V
Permits may be voided if site is alter �
Well and Septic Layout by
Comments:
Size of Tank P �� �
Size of Pump Tank 1�- �
Nitrification Line G
Max Depth Trenches
in compliance with zoning regulations.
Date `�/'/ �" '7� Installed by i�� ' r-. Approved by.
Well Permit Paid ❑ WELL SYSTEM SPECIFICATIONS
ividual Semi-
Site
Wel
Date
d Approved
Approved '
Installed by
�equired Slab
Air Vent
Required og _
W ag
pproved by,
�
CG4`�
This report is based in part on information provided the homeowner ori�fis/her representative in the applicatioti submitted for this permit. The
environmental health specialist is not responsible for false or misleading information contained in the application. The emironmental health
specialist is also not responsible for concealed conditions on the propeRy or for statements in this report that may have resulted from false or
misleading statements provided ro him in the applicadon. Neither Person County nor the environmental health specialist warrants that the septic
tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro\permit.sam 01/95 rev.1.0
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Improvements Permit (Established/Recorded Lot)
Improvements Permit (Unrecorded Lot)
Permit (Mobile Home Replace)
Improvements Permit (Addition)
�-d-�-�,.
Reinspection of Existing System (Loan Closing)
Repair/Replace existing 5eptic System
Permit for New Well
_ Replace Existing Well
1. Permit requested by: 7. Dimensions or Proposed Structure: ,
owner/prospective owner/agent: ��a�� a� �� idth: �� � 7D �c p�a�- S"v� ��
d d r e s s: �,// G%� rd�w � l✓�` u S l v� , e� D e p t h: w� c� e w'� � Sa.�,�
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?
ome Phone #: c� s� s� y/
usiness Phone #:/ �lU� GG2 3 3 L�
2. Name and address of current owner: 9. Water su,pply type:
�l'l �� � 2 �/� 7��►✓ private C�7�public ❑ community ❑ spring ❑
/ v N b �' Nsi /� Are any wells on adjoining property?Yes ❑ No ❑
If so, identify location:
3. Property Description: Lot size: ����►�
. Tax Map#: �'% 10. Type of structure/facility: Proposed: ❑Existing: ❑
Parcel#: � Type of dwelling:
Township: d� Ve � i 1 � House: ❑ Mobile Home: ❑ Business: ❑
5. Directions to property: State Road #& Road Type of business:
am�je�. l3 � Number of Employees:
� � L 6 Number of bedrooms: 3
Garbage Disposal? Yes ❑ No 0'
Basement? Yes ❑ No �Tf so, # of basement fixtures:
6. Number of occupants or people to be served: �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY ANll 'l�ii� C;UKIV�KJ Ur� ALL _
PROPOSED STRUCTURES.
I hereby make application to the PersOn COu11ty Health Department 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.
�,�/`c�,
Signed Owner or Authorized Agent
. . . �, ---.
Permit Issued ❑ Signature
Permit Denied ❑
Plat Observed ❑
Date
FACtORS-51'IE EYALUATTON ARFA 1 AREA 2::: 11REA 3 ARFA 4;
_:.::
1. SLOPE (9F) S � S S� � S
PS PS PS PS
U U U U
2. SOIL,T'E7CTURE(12-36IN.) S S 5 S
(SANDY, LOAMY, CLAYEY, NOTE 2:l CLAI� PS PS PS PS
U U U U
3. SOfL STRUCTURE (12-36INJ S S S S
(CLAYEY SOILS) PS PS PS PS
U U U U
4. SOIL DEPTH (W.) S S S S
PS PS PS PS
U U U U
5. RESTRICTIVE HORiZONS (IN.) S S S S
(IMPERVIOUS SiRATA, ROCK) PS PS PS PS
U U U U
6. SOILDRAINAGF/GROUNDWATER S S S S
(EX7ERNAL & INTERNAL) PS PS PS PS
U U U U
7. SOIL PERI�tEABILTTY S S S S
(PERCOLOATION RA7E) PS PS PS PS
U U U U
8. AVAILABLE SPACE S S S S
PS PS PS PS
U U U U
9. SITECLASSIFICAilON(SEEBELOW)
SOIL SERIES
S•SU[TAHLE PS-PROVISIONALLY SUI'CABLE U-IJNSUITABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.� C:WMIPRO�DOCSIAPPSEC.SMFAIANCE.PC
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SR l307
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