A27 221�
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.a5 e���aluation Application
Fee Collected YES �
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Date: ���� . `
,
APPLICATION FOR IMPROVEMENTS PIIiHIT
1. Permit requested by: ownerfprospective owner:
agent:
Address:
Home Phone �� :
2. Name and address of current owner:
Business, Phone �i:
3. Property Description: L�t size: /�.� '� I� ��`�
4. Tax map ��: � -Township: ��
Subdivision Name: �r�Qr.��� � Lot ��:
5. Directions to prop
��L�s �- t.��
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• State .Road �� & Road Names, etc.
r� � , � �,L f�� �i�- ��CJ "7
6. Permit requested for: New Installation: 1� 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? v public? community? spring?
Other source? (Specify):
Are there any wells on adjoining property? If so, identify location:
11,
Type of structure or facilit,y:/� roposed: v Existing:
Type of dwelling: House: V Mobile Home: Business: _
Type of business: Number of Employees:
Number of bedrooms: Garbage Disposal? Yes No
Basement? Yes Iv'o If so, number of basement fixtures:
12. Clearly stake a17. corners of the property and the corners of all proposed structures.
I hereby make application to the Person County Health Department for a site
evaluation or existing system evaluat3.on 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 becom 'nvalid.
Permits are valid for 60 months from date of is . Permission is he y granted to
enter the property for the evaluation. G.S. 1 335(F)
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Permit Denied
Plat Observed
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i�ACTORS - SITE EVALUATION AREA 1 AREA 2 ARF,A 3 AREA 4
l. SLOPE (X)
. SGII. TEKTURE (i2-36 in. )
(SandS, Ioamy, clayey,
Note 2:1 clay)
. SOIL STRUCTURE (12-36 in.
(Clayey soils)
4 . SOZL DEPTii (i.n. )
.5. RESTRICTIVE HORIZONS (in.)
(Im�ervious Strata� rock)
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SOIL DRAINAGE/GROUNDWATER
(F�cternal & Internal)
SOIL PERMEABILITY
(Percolation Rate)
$. OTHER (specify)
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9. SITE CLASSIFICATTON � , 1
(See below) � �%
SOIL SERZES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECOP4�21DATZONS / COMMF�TS :
S�TE CLASSIFICATZON �IAGRAM (IncLude: Soil areas, property lines. roads, streams, gull.ies,
wet areas. fill areas, wells, crater bodies, slope patterns, etc.)
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IS S89'32'28"W
LAWRENCE GRINSTE�
IF
CONTROL
CORNER
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date: � � �� '
` OWfler: V; cT6 r/3o�d1a l�q �; n � SR#
Location/Directions: �
Subdivision �N�une: __ Lot #
Drilling Contractor: �<<'f�r /.�G���rre
WEL,I. CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollution
Total.Dep.th:� f�v Ft. Yield: �( 6 GPM Static Water Level .2 S Ft.
Water Bearing Zones: Depth yo -�, Ft.�-3 r�F� F� �t.
Casing: Depth: From_�to 3 6 Ft. Diameter. �%y Inches
TYPE: Steel � Galvanized Steel
If Steel, does owner approve: Y�s No
� Weight: � Thickness: Height�Above Ground: Inches
Drive Shoe: Yes No . � �
Were Problems Encountered in Setting the Casing? Yes No `�
If "yes" give reason:
Grout: Type: Neat SandJCement �^_Coricrete '
Annular. Space Width Inches
Water in Aruiular Space: Yes No
. , . _ .. Method: Pumped - �Pressure . Poured_ �' � - . . . . - __ . . _ ..
Depth: From D to 2 v Ft. � -
Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes � No � ' ` � �
4 x 4 slab Yes� No
I HEREBY CERTIFY THAT THE ABOVE INFORMr�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C�Ui�iTY HEALTH DEPARTMENT.
ignature of Contractor Date
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlvIPROVEMENT PERNIIT
Tax Map # � � Parcel # �� /
Zoni`g Township / ' i/� %� i/
Owner/Contractor " Y ��a t� j� Date t�- L-�f _ 9�
Location/Address_ �{,e � � ,�c, S'�'� �_ / �t� ''7 �r� s•� -� /_30 �
� � � S.R.# / ���
Subdivision Name
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Lot#
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SEWAGE SYSTEM SPECIFICATIONS
�ir Lot Area %. 70 Gi cv�s Size of Tank �
� Mobile Home Size of Pump Tanlc N 1 A
ness # of Bedrooms_�_ Nitrification Line �c70 ')(_3 �
Max Depth Trenches� 6 �' ^
Pernut Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or ' n d use chan ed.
Well and Septic Layout by Ql ��nit-..o
Comments:
Date
Installed by � ('a11�P Approved by,
SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab ✓ 3� _
Public Replacement Air Vent
Site Approved '✓ tf� Required Well Loo ✓ tt�P -
Well Head Approved Well Tag ✓ �1 _
Grouting Approved f�-�
Comments:
Date Installed by � K� � Approved by
71us report is based in part on Wmmation provided the homeowner or his/her representative in the application submitted for this pertnit 'Ihe
environmrntal health specialist is not responsible for false or cnisleading infortnation coirtained in the application. The environmrntal health specialist
is also not responsible for conccaled conditions on the property or for statemenb in this report that may have raultcd Srom false or misleading
statements provided to him in the applicatioa Neither Pecson County nor the environmental health specialist wazrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable.
ORIGINAL
c:�amipro�pemtitsam O1/95 rev.1.0
t��plication Date: 7-oZ �'� 9 - � TaY tilap: A� 7
Amount Paid: j.�0 .()O Farcel �: _ 2 2 _
Receipt�#: � 7��14 �
�+;# � ��� `� � a..�I�..� 1 �.�
— �` ��> � �'��� �' �
I.L , az�i �a—:i�r � �3 r,-,.-„ <c-r •r.i,L':,ez � 1�.'�� <c:�..^a � 4` �cz
1����gc���o� �o�' �e�'vie�s (Septic Systems and Wells)
Se3-vic�s �e ues�ed
� �mprovement �ermit (Site Evaluation) ❑ Construction r'�uthorization
�200.00/$300.00 (if> 600 g d) (Fee is dependent on the tyne of system ermitted)
viobile �iome.iteplacement or �uilding �ddition ❑ Permit Revision
$1�0.00 (if site visit required) $75.00
❑�'Qil �ermit (Pdew/Replacement/12epair) O Repair of ��isting Septic System •
$300.00/�200.00/$75.00 No Charbe
l � ) Servic�s 32e uested.'n :1 '
Name: � F � h'c ��`^'S Phone # (home):
Address: e4� �' t� uz�. (tvork7cell):
SZ�����, � � a�� � y
�-v`C' c(�3 �
i)l��m� ��d adc�rQss off z�arr��mt aw�ea- (s� differ�n# �h�an applicamt):
Name:
Address:
�) ���g�er2y �escrfip�io�: Lot Size: �. 7� Subdivision:
Address and/or directions to Property:
J' aSo� ���1
�ot #:
4) �roposed Use nc� 'T3�pe oi Stract�ere: ,—� �
R�sidential � Business/Type: Other a-� k�� ��"�� ��
Nur.lber of bedrooms 3 / Number of people served (seats/employees):
Basement: Yes � No (with plumbing: Yes No �
Garbage disposal: Yes No
,frj �Vater Supply�
� Private Well �� (Proposed Existing �
Community Well: Public tiVater Systein:
Are there wells on the adjoininj properties? T10 Yes
(please show location on site plan)
1'�I�t�: � eonap[eterd crD�laealion mu�E c�dso ineluc�e:
���lat/site pluaz of tlie �r�pey:y �Iia1 slta�v� ��o�e�-� rliy�en�ions car�c� t�ce �izD �pad �ocntion a�`',�dl
�roposed stYuctures. .
y�1 sagned capy �f'llie `�at ����esration',�'or:aa veri��a�a� ihat llae �ropeYry �s ready io be. ev�al�u�e�.
� a� saabmittin� #hes ��pol�catioca #o r��a�esi 3ervic�s �ro� t�e i Qrson �ou�ty ?�e�lth �epaa-#une�t. � uneersta�d tha�
iff th�e infm�-�ation �rovided as i�eo�-rp�t �a- i� #he ��#e :s s��s��ue���y ��2ere�, �r if #h� �aatendeai u�e c�arg�s, :��fl
per�an�ts a�d apprava�s shai� became invalid. -
��g�a�,i�-� {Owner!Legal Re�resentative);/� � a5� :
10i08 Person County inviron�nen2al_ '�ea�th; 3"'S S. iiior�an �t.; Suite C; R�Yboro, NG 2757� (33E-�Q7-1790)
►
VICINITY MAP
LECENO
NF • NAIL FOUN�
NS o NAIL SET
IF • iRON FOUNO
IS o IRON SET
NP o MATHEMATICAL
POINi
UNLE55 S�pED, SEALED AW DATEO. 7H[5 IS �
PREL[YINART PI�T, NOT FOR RECOROA7I�N, SI.LES
OR CONYETIuiLES.
{�W/t�Tf-�NI►� �
hS50(:N
REGISTERFD IAND SURVlI'ORS
I14 JMIES STPEEf - P•0. BOX 1266
ROXBORO NONiH CARUl1N� 27573
(910) S89-B7a2
__ _ _ _
NOR�M CARGLIN�Q�`_� COINif
nc so�oo�Mo c�rvtu*� ar flnt:_• �� -P..,.:.ti
Mor,ur ninic a n[ oo�isatwra wt�ts�au'�[o
�s cunrrm ro rc taiwccr. m�s n�r us ncsdrm
ra e[asnun� wo aC�Q�D �w nits arrta ar
/LA1 W IKi � ►.� �} TMIS 11 0{Y Of
_� ��r____. 1 Ly(_ AT =$! _ 0'CLOCI( P_Y.
--�.�..�_�r....�4.,dL�_
ac�sru a ams
REVISION OF
LOTS 10, 11, 12, 13, & 14
RICHLAND CREEK ACRES
OLIVE HILL TWP., PERSON COUN7Y, N.C.
JULY 1994, HAMLETT—JENNINGS 8 ASSOCIA7ES
NEAL C. HAMLE77 L-2465
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P.C. 6. P. 1 - � 1. 7O
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IF seo•a2�za•� IS seo•as�xe•� 15
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10P FARYS, INC.
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IKGISTIUIIOM M�bE� 1VD SL��L TMIS .IL ORY
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�uiflc���ag Ad�.gtio�s/ IVlo�si�e �offie �e�lac��aae��
Tax Nlap #:-2� Parcei#: 2Z �
Approval Requested for: Mobile Home Replacement
� � Buildi.ng Addition
Applicant Name:
� -f - ,S��Pw �Jrf � � 45� ���'�t Sn�' `{�3(P
Address: c0� o
Phone #'s:
\ Permit Located: � Yes No
Installation Date: Design flow: ��O � (gpd)
Current Contract with Certified Operator on file (if required): N�Q
_� .
Water Supply: �_ Well Public or Community
Wastewater system.shows no visual evidence of failure on: 4 D (date)
� (Applicant's sign�ature if site visit is not required)
� r�r�dii�ori�teplac��ent App��v�
�"'' e-c 7 Z F o
Environmental Heaith Specialist Date
`� 11/l�/OS
}'a�e 1 o f 1
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6869 , ,.:: . ` :
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DEEDBOOK
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DEEDPAGE � �� � ' �
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RECN TAXMAP PIN DEEDBOOK DEEDPAGE PLAT NAME SITUSADDR ROUTE CITY SAL
9976- CREWS OH
� Tax 6869 A27 221 00-94- 371 718 9/19/2 W�OTHY DO oo� SON 106 COUNTY 4/1
" Card
4070.000 095
CHERIE S
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