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A27 216f « _ �erson •Count Sewage System z y Health Department � Improvements Permit Date: 3' This Permit Void After 5 Years Permit #�� Owner: e n� %�� L�l�t � lt�� !� SR# �gf� Location/D'uections: ! � e ((� Subdivision Name: " Lo[ # Lot Size: � Type of Dwelling: Water Supply: Private: Public: Community: Bedrooms: �� Garbage Disposal Basement� � -Basement F' es � INFORMA OTI N CERTIFIED BY � � Environmental Health Specialist: owaer res�a�au�e � REPAIIt: REEV UATION: ------------------------- Size of Septic Tank: %Q�� gallons Size of Pump Tank: Nitrification Line: ��n� %�( � � Depth of Stone: 12 inches Max Depth of Trenches: Altemative System: Conv. Pump LPP Pump Remarks: Date Well Approved: BY Date age te BY ` Contractor. Well should be 100 f� from any sewer system Enviropmental„Health Specialist 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 nirsification 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 nse change this permit is subject to revocation. (G.S. 130 A-335F) Location of sewage disposal sewage system sketched on back. (OVER) N�OTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water � su�plies, 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. f i �.� : il) (2) � �� . � ��i�%��■� ��e� ��Q:�: � :; ��`��■ ■��■��■ ��'`,::�c'�*��■ ��■��■�■ s��a�� e■�e��■ ��■��v��■ ��■��■ �� ■■��.��■ ■��i��■ ��■s��■ �e��:::�■s��■ ■��■ ��■�■ ■��■ ■■�■��■��o ■��e��■ ■��■�� ►��■��n�■ ■��a��i�� ■■��■ � ��•...�. � � ., \ � � Person County Health Departn ' ' -' Well Permit - Date:�This Perm t Void After 5/ Years ,/ Own�r �,�� h �,�f-�—��f��7�SR# �� Locauon/Duecuons:. Subdivision Name: _ Drilling Contractor. Distance from Nearest Property Line YJ l � s Distance from Source of Pollution b A u.S Total Depth:,�� FG Yield_� d GPM Static Water Level�_ Water Bearing Zones: Depch �' v Ft.��F� FG �� Casing: Depth: From � to�.�� ' Ft. Diameter:�_% Inches TYPE: Steel �( al�anized Steel �--- If Steel, does owner approve: Yes No Weight��_ Thiclrness: � eight Above Ground:_��eh Drive Shoe: Yes No Were Problems Encountered in Setting the Casing? Ycs No ` If "yes" give reason• GrouG Type: Neat Sand/Cement Concrete Annulaz Space Width `� i Inches Water in Annular Space: Yes No L� Method: Pumped Pressure Poured L-- Depth: From_�_ to�_FL Materials Used: No. Bags Portland C�nent� Weight of 1 bag� If mixture (sand, gr�l, cuttings) - Ratio: ' a� to� � ID Plates: Yes No_ 4 x 4 slab Yes�No_ I HEREBY CERTIFY THAT THE ABUVE INFORMATION IS CORRECT AND 7 THIS WELt, WAS CONSTRUCTED W ACCORDANCE WITH REGULATIONS FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. G�!`�— ��.Q`L' / Si ature f C n ctor Date ' � 3 �/ anitanan s i ature ate Issued Sanitarian s Signature Date Complet< ^'-�t�h weli location on reverse side. � H O � � W � a � �d a�.�la� �� g-a-q.� �� e APPLICATION FOR SERVICES , , ti Services Requested. : , _ _ _ _. Improvements Permit (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing) Pernut (Unrecorded Lot) Permit (Mobile Home Replace) Permit (Addition) Repair/Replace existing Septic System Permit for New Well _ Replace Existing Well Permit requested by: � �vner/prospective owner/agent:f��c,tnef le C. ��ackwe� ddress: i � �Rober•f-son'(�d • oxbaro N� a 7S'7 3 ome Phone #: a � �-s9Q'S'� � � usinessPhone#: �t1�-S'`iR�ll9s ��'�'��.�r�� 7. Dimensions or Proposed Structure: Widch: Ic' r a�' Wo�k�'�pJ Cwi'� 6��o�cl'�) T�enth � QLt�4'� b � 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? N on �. - w e a.r� r1� s�Q,p ( y irlQ l,da�c-r '�-d . Name and address of current owner: 9. Water supply type: SQXV�e� private � public ❑ community ❑ spring ❑ Are any wells on adjoining pro erty?Yes IA1 No ❑ If so, identify location: S00 ��-• (neiytG+focfn c��-) . Property Description: Lot size: 7. �� . Tax Map#: a�� 10. Type of structure/facility: Pro osed: �Existing: ❑ Parcel#: a I b Type of dwelling: �WdrK� �'�o) Township: C�I ��JG Fh�II House: ❑ Mobile Home: ❑ Business: ❑ . Directions to property: State Road #& Road dames, etc. l5's W-�-t�m �i'ahto�v�.lohn U)i,ns�-ead R�. � �D . Number of occupants or people to be served: of business: Number of Employees: Number of bedrooms: N � j� Garbage Disposal? Yes ❑ No � Basement? Yes ❑ No C�l 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 PersOn COunty Health DepBI'tment 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. �- � . I l, I� Signed Owner or Authorized Agent Pernvt Issued ❑ Signature Date -► ' * Per�it Deried ❑ Plat Observed ❑ ,�ACTORS-511`H EVALUATibN ARF.rS l AREA 2::: pREA 3. ;% AREA 4 _ _ ,, > l. SLOPE (%) S S S S PS PS PS PS U U U U 2. SOII, 7EXTURE (12-36IN.) S S S S � (SANDY, LOAMY, CLAYEY, NOTE 2:1 CLAS� . PS PS PS . PS U U U U 3. SOIL 57RUCTURE (12-361N.) S S S S (CLAYEY SOILS) PS PS PS PS ' U U U U " 4. SOII. DEP7'H (IN.) � S S' S S •� . PS PS PS PS ' U U U U • S. RESTRICi7VE HORIZONS (IN.) S S S S (iMPERVIOUS STRATA, ROCK) PS PS PS PS U U U U 6. SOIL DRAINAG&GROUNDWA'IER . S S S S (EX7ERNAL Q Q9'l'ERNAL) PS PS PS PS U U U U 7. SOIL PERMEABILI7Y S S S S (PERCOLOA710N RATE) PS PS PS PS U U U U 8. AVAILABLE SPACE 5 S S S PS PS PS PS U U U U 9. SiTE CLASSIFICATION(SEE BELOW) SOiL SERIES S-SUITABLE PS-PROVISIONALLYSUI'fABLE U•UNSUITABLE RECOMMENDATIONS/COMMENTS: SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope patterns, etc.) C:�AMiPRO�DOCS�APPSEC.SM FINANCE.PC - C��4� „ � , PERSON COUNTY HEALTH DEPARTMENT Q • WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT � Tax Map # ��r% Parcel # �/l� ! Zoning Township �" � a' Owner/Contractor Date g- _? - R�_ Location/Address � a S/�1/- -3Q s.R.# D � Subdivision Name ' � Lot# .� y , % {�E=�,a+,,��'�e {, � � Layout � � ��a�� ,�, ,S�-e u� s r�' �— -j�i S P.e �-n�� f- W� i I-�'h -b ��.Q.fln� a�d,k-`��, � �o�ks►,.p ��a�' �w rn j.,a vy� a,� � Go �� Gr �- t�ur� a�d ��.�"eo v�e� i- 7� h� �Sz wi,�. -E-� v v� � ✓s�� .�- .�P� re ��' � ,� � co�c� P.�vr�. o v z v �r,'s fi;� S,�,r c�ys�� a ,..� ��' .�Re w o ✓G�s �� W��`, �►�� .e b�if� ode;✓a7(ijh. s � fi'� � ,,,,�. ho,r�e wt rn� � �,c� �-,�.e � a� r�� _ c� SEWAGE SYSTEM Zepair Lot Area � c�r ►FD Mobile Home �ss�� i��_p # of Bedrooms w r,{ti �� r� ,,�0 4�� -.:.1. o� � As Installed �f�-,# 13d� -� � r— X�u �s�� -o v I� fi Co�T�I� � �'l CATIONS � s�� Size of Tank � ' ��2 I-� ts Size of Pump Tank ��i�� Nitrification Line �P!Z'�c,�.� i1r�0 �c 3� Max Depth Trenches Permit Void after 60 months. Permit Void if not in compliance with zoning regulations. Permits may be voided if site is altered or intended use changed. Well and Septic Layout by �� _S� �er �'1,r --___ � SyS� , P�� 41 g -5b3 % 0..2 9 IWell Permit Paid ❑ WELL SYSTEM SPECIFICATIO�_ � Individual Semi-Pu Public Replacen Site Approved Well H proved Gr tin� Annroved Comments: Installed by, ired Slab Air Vent Required Wel We by This report is based in part on information provided the homeow`fier or his/her representative in the application submitted for this permit. The environmental health specialist is not responsible for faise or misleading information contained in the application. The environmental 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 Person County nor the environmental health specialist warrants that the septic tank system will continue ro function satisfactorily in the future or ihat the water supply will remain potable. c:�amipro\pettnit.sam 01/95 rev.1.0