A27 219�„_ z
�--•�son County Health Department �
Sewage System Improvements Permit
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Dat�: ' This Permit Void After 5 Years Permit #
Owner: SR# / OC�
Location/Directions:
Subdivision Name: T/� r'G�i /Ga �( (-lP��/ �y�� Lot #,�
Lot Size: �;�� ��T�' Type of Dwelling:
Water Supply: Private: —�� Public: Community:
Bedrooms: � Garbage Disposal
` Basement Basement F' s �
INFORMATION CERTIF'IED BY �
Environmental Health Specialis . er or ta�i�e
REPAIR: REE ATT . _
Size of Septic Tank: �/��`b""__ gallons Size of Pump Tank: ----
Nitrification Line: �/'7Q '� �( � �
Depth of Stone: 12 inches
Ma�c Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks:
-------------------------
Date Well Approved: Well should be 100 f� fmm any sewer system
BY Environmental Health Specialist
Date Sewage System Approved:
BY Environmental Health Specialist
CERTI�iCATE 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 hazazd. Septic tank and
ni!rification 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 use change this pemut is subject to revocation. '
(G.S. 130 A-335F) . . _ --
L.ocation of sewage disposal sewage system sketched on back.
_ _.
(OVER)
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
u�iplies� etc. Note special problecns existing on lot. Write in measurements in order that installations may be located
t later%date. Note location of water supplies on adjacent lots.
. �
.bite '£valuation Application
;e�pGallected YES /
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Date:
APPLICATIOId FOR IMPROVEMENTS PERHZT
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1. Permit requested by: awne prospective owner: %�o ry� �-S �o
agent: �i�r/�7-�_--�
Address:
Home Phone �� :
2. Name and address of current owrier:
nusiue5� CIlV11C v:
3. Property Description: Lot size: �,%�j�
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4. Tax map ��: /-} �,7 Township: ��j �/� /�//
Subdivision Name: _� , ���qiyi) �/C �-fL_ Lot ��:
5. Directions t��' property: State,Road �� & Road Names'. etc:
/5-� ;`�-,-� �~f' �ry �L /� 0 7 /� �f c�� �S�
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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: %
8. Dimensions of Proposed Structure: Width: Depth: _
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? ✓
Other source? (Specify):
Are there any wells on adjoi:
11,
public? community?
ng property?
If so, ident
spring?
ifv location:
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 ro
Basement? Yes No �f so, number of basement fixtures:
12. Clearly stake all. corners of the property and the corners of all proposed structures.l
�
I tiereby 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 her by granted to
enter the property for the evaluation. G.S. 13 335(F)
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Sig ed Owner or Authorizec Agent
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Permit Issued _�
Permit Denied
Plat Observed _�
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i�ACTORS - SITE EVALUATION AREA 1 AREA 2 ARF.E� 3 AFtEA 4
S S S
1. SLOPE (X) PS PS � P�S
U U �r
2. SGTI. TEXTURE (i2-36 in. ) S S � S . S
(Sandy, loamy, clayey, PS ' S PS j S (J�x
Note 2:1 clay) U
3 SOIL STRUCTIJRE (12-36 in. ) g
(Clayey soils) _ PS PS PS _S
S S S S �
4. SOIL DEPTEi (i.n. ) /� PS PS S�
�
.5. RESTRICTIVE HORIZONS (in.) S- S S S
(Iu�ervious Strata� rock) PS PS PS S
,u
6. SOIL DRAIt1AGE/GROUNDWATER S S S S
(�cternal & Inteznal) S
�- U �-
7. SOIL.PERME�ILITY g _ g S
(Percolation Rate) � PS_ PS PS
U U U U
S S S S
$. OTHER (specify) PS PS PS PS •
U U U U
��. SITE CLASSIFICATZON � �
(See.below) � S
SOIL SEiZIES
S- Suitable PS - Provisionall.y Suit-able U- Unsuitable
R FCOt�QiENDATIONS /COMMFSITS :
S:�:TE CLASSIFZCATZON �IAGRt1M (Znclude: Soil areas, property lines. roads. streams, gullies,
c�et areas. fill areas. c�ells, �aater bodies, sZope patterns, ete.)
�
( ) Improvement Permit
1.
2.
3.
4.
APPLICATION FOR:
(� Subdivision
Date Received:
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( ) Other �
Permit r quested by(� (, ��I�� C�OL�67L/�I Home Phone-_����
Address:� �� %(O O�yS SiW-� Business Phone
Name and address of c rent owner: �i l�!-�L��� ��"�� /�'�I�� J
/�r-� �vX�2p
Property Description: Lot size ��� �� Dimensions:
Front t�O � Left Right Rear
Tax map No. Township:�����% if«LBlock No. Lot No.
5. Di� ections to pro erty: State Road No. & Road Names etc.
l�l�,C�rN- Gen� �`� Lc�- On� G.A�C�'S S�/'� �� L
i l��/
6. Permit requested for: New Installation � Repaired
Additional Renovation re-using present system
7. Number of occupants o£ people served�
r i
8. Dimensions of Proposed Structure: Width �� Depth Z-�
/
9. What tyYe (if any) additions, expansions, or�replacesnent is ani.icipated
te the structure or facility that this sewage disposal sys�em is intend
to se�ve? '
�
�.� �'�- _ _
10. Type of water supply: Well %�yes no: If ao, name source of water
supply: Are there any wells on adjoining
property? If so, identify location.
il.
Type of structure or facility,: Proposed� Existing
Type of dwelling: Hovse�^ Mobile Home Business
Type of business • Number of Employees
Number of Bedrooms ,� Number of automatic� appliances
Basement�_ Number of basement fixtures
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12. Clearly stake all carners of the property snd the corners�of all prop
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 conten
of this application are true and represent the maximum facilities to be
placed on the property. I understand that if any changes are made without
approval from the Person County Health Department, the permit will be void
Any permit for a system is non-transferable witho prior approval of the
Person County H�alth Department. Perm'� �re val��/f �r�b �onths from dat
of issue. /111 � V �/ I/1
SIGNED
FACTORS - SITE EVALUATION
1. SLOPE (%)
2. SOIL TEXTURE (12-36 in.)
(Sandy, loamy, clayey,
Note 2:1 clay)
3. SOIL STRUCTURE (12-36 in.
(Clayey soils)
4. SOIL DEPTH (in.)
5. RESTRICTIVE HORIZONS (in.
, (Impervious Strata, rock)
6. SOIL DRAZNAGE/GROUNDWATER
(External & Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
S
S
P
U
S
S
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S
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U
S
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U
S
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AREA 1
S
PS
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U
S
,E�
U
S
B�
U
S
S
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U
S
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U
S
AREA 2
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
P3
U
S
��:i�Tt7
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AREA 4
S �
PS �
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
8. OTHER (specify) PS PS PS � PS
. U U U U
9. SITE CLASSIFICATION ---
(See below) �
SOIL SERIES --
S- Suitable PS - Provisionally Suitable U- Unsuitable
RECO1�II�tENDATIONS / COMMENTS :
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies,
wet areas,.fill.areas, wells, water bodies, slope patterns, etc.)