A27 215�
�erson County Health Department
Sewage System Improvements Permit
Date: '� ` This Permit Void After 5 Years Permit #
Owner: SR# ��
Locadon/Directions:
S ubdivision Name: �_i� ��'n d C j'P� /� C�'� s Lot #�
Lot Size: �1 Type of Dwelling:
Water Supply: Private: Public: Community:
Bedrooms: 3 Garbage Disposal /1%0
Basement Basement F' es —��s�
INFORMATION CERTIFIED BY -�
Environmental Heallh Specialis[: er or resentative
REPAIR: REEVALUATION:
Size of Sepdc Tank: �� gallons Size of Pump Tank:
Nitrification Line: L-�/�/) � �3 �
Depth of S[one: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remazks:
Date Well Approved: Well should be 100 ft. from any sewer system
BY Environmental Healih Specialist
Date Sewage System Approved:
BY Environmental Health Specialist
CERTIFTCATE OF COMPLETION
Contractor:
Sewage System location, installation, and protection must meet state and local
regulations. Septic tanlc 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
nitrification line must be inspected and approved by , a member of the Person Counry
Health Department before any portion of the installation is covered and put into use. If
the site plans or intended use change this pernut is subject to revocation.
(G.S. 130 A-335F) . _ _ __
I.ocation of sewage disposal sewage system sketched on back.
(OVER)
NOTE: Make sketch of instailation 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 located
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. later. date. Note location of water supplies on adjacent lots.
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Site Evaluation Application
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Fee Collected YES
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Date: �l - '2 `� - `1 �
2d0
APPLICATT_ON FOR IMPROVEMENTS PERHIT
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1. Permit requested by: owne 'prospective owner: ��'/o �iA-S �� �
agent: �}-m�/�%� �'c
Address:
Home Phone �� :
2. Name and address of current owrier:
Business Phone ��:
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3. Property Description: Lot size: ��� a
4. Tax map ��: �2,� Township: �1/��/� /7,%/
Subdivision Name: �,��/��yi� �e � fL_ Lot ��:
S. Directions tf' property: State Road �� & Road Names, etc.
/ S-� Gu �� rH /'�" U/Y .�/L�� � 7 �� �i� f� /1� �� �.
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6. Permit requested for: New Installation: V Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served: %
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8. Dimensions of Proposed Structure: Width: Depth: I
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 th/e,�re � Ly yells�on adjoining property?
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community? spring?
If so, identify location:
11, Type of structure or facility: roposed: V Existing:
Type of dwelling: House: Mobile Home: Business:
Type of business• Number of �oyees:
Number of bedrooms:� Garbage Disposal? Yes No
Basement? Yes No ✓f so, number of basement fixtures:
12. Clearly stake all corners of the property and the corners of all proposed structures.
I Yiereby 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. 13 -335(F)
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Signed Owner or Authorized Agent
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Permit Issued
Permit Denied
Plat Observed �� �
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i�ACTORS - SITE EVALUATION AREA 1 AREA 2 ARF.A 3 AREA 4
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1. SLOPE (X) PS PS PS PS �
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2. SGli. TEXTURE <i2-36 in. ) S . S
(Sandy, Ioamy, clayey, PS � PS j '
Note 2:1 clay) U tj
3. SOIL STRUCTIJRB (12-36 in. ) S S
(Clayey soils) PS PS _S
4 . SOIL DEPTH (a.n. )
5. RESTRICTIVE HORIZONS (in.)
(Impervious Strata� rock)
6. SOZL DRAI2�#GE/GROUNDWATER
(bcternal & Internal)
7. SOIL P�RMEABILITY
(Percolation Ratc)
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$. OTHER (specify) PS PS PS PS •
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9. SITE CLASSIFLCATZON � ( O�
(See below) J
SOIL SERIES
S- Suitable PS - Provisioually Suitable U- Unsuitable
RECOr44ENDATIONS /COMMFI�ITS :
S:tTE CLASSIFICATZON �LAGRAM (Znclude: Soil areas, property lines. roads, streams, gulZies,
Wet areas, fill areas, wells, water bodies, slope patterns, etc.)