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„� ��i.� �:�'son County Heaith Department
Sewage System Improvements Permit ,_
Date: ' This Permit Void After 5 Years Permit #��~��� ��''
Owner: SR# ��.
Locadon/Directions: E' �"
Subdivision Name: � �`'%'�'�r Lot #
Lot Size: << ���±-�' -r Type of Dwelling:
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Water Supply: Private: � Public: Community:
Bedrooms: '-'� � Garbage Disposal
' Basement Basement Fixtures �. .
INFORMATION CERTTFIED BY -�-�-- M -��
Environmental Health Speci.alist: �ei o� resentative . j
REPAIR: REEV - ATI �� �°�
Size of Septic Tank. �}�� �✓ ^ gallons Size of Pump Tank: �
Nitrification Line: • -��'�� tr— — f — —.— — — — —
�i1�� �
Depth�of Stone: 12 inches
Max Depth of Trenches:
Altemative tem: Conv. Pump - LPP Pump
Remarks: �c.a rvi n " C� � .�, �-✓'.��s� r� "��r-�� .-l.. �
Date Well _ApprQved: �? � Well should be 100 ft. from any sewer system
BY � Environmental Health Specialist
Date Se g Sy m pprov � ���.�==���""
gy Environmen[al Health Specialist
CERTI CATE OF GOMPLET'ION �
Gontractor. �: �La ..,,' c �
----.---------------------�----- �.
Sewage System location, installadon, and piotection must meet state and loca� �
regulations. Septic tank should be pumped out every 3 to 5 yeazs, and shall be maintaine�:; .'
by bwner in such manner as not to create a public health hazazd. Septic tank and
rii[rificauon 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 tlus permit is subject Co revocadon. • ,
(G.S.130A-335F).. . ': ....� ;. A
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Location of sewage dispdsal s�wage system sketched on back. .
.. .. . .... . .. (OVER) . . ...
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Person County Health�:Dep�artment �
Well Per � �:
; Date:�'��This Permit Void AfterS Years�,.. SR# .�%3ob_ �o
Owner. �
Location/Directions: r
Subdivision Name: n �#'�R c Y� L.ol �
_ Drilling Contractor. '
- WELL CONSTRUCITON
Distance from Ncazes �r� ty Line � 7 ws Disiance from Sourcc of
Pollution d � � � �'"
. Total Depdt:�_ F� YicId:�_ GPM s"Static Watcr Lcvcl ���F�
' Water Bearing Zones: Depth ,�d a FG��F''C�` F4 Ft.
Casing: Depth: From�_to_ o"L1 F� D�ameter:�inches ►d
� TYPE: Steel Galvanized Steel � n
If Steel, does owner approve: Yes No c�,
. Weigh� 13 Thickness:��ghf;Above Ground:�_�nches �
prive Shoe: Yes_�1Vo �,.;
, Were Problems Encountered in Setting the�asing? Yes No �
If "yes" give reason: �
, GrouG Type: Neat Sand/Cement � Concrete
. S : }Y.
A.z.ularSpace Wid:h 3 Incne�s.,�f.
;� Water in Atmulaz Space: Yes No'�' ��
, ]ylethod: Pumped Pressure °�Po�sed ��
'� � Depth: From���_F 5
Materials Used: No. Bags Poriland Cem �: •:� Weight of 1 bag�_lbs.
If mixuue (sand. gravel, cuttings) - Ratio: �,� � to f ,b
, � ID Plates: Yes�o � - Z
4 x 4 slab Yes ,/ No � I
• DRILLING I,OG�' �
De th ;F:
From To Fotmadon Descri cion
. �
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, , � �
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT �
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET �
- � FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. �
�.�r
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of wC-ontractor Date
G-2�t-� �
S 'an Si ature Da Issued
'� � ' � , • '7 ., ] .�
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' Sanitarian Si ` ure Date Completed
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Sketch well location on reverse side. . •
Site•E;daluation Application
Fee Collected YES ✓
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Da t e: l�T/��f i`
APPLICATION FOR IMPROVEMENTS PIItHIT
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l. Permit requested by:
Address:
Home Phone �� :
owner/prospective owner:
agent:
2. Name and address of current owner:
3.
4.
S.
Business Phone ��:
Property Description: Lot size: �� /tJ �
Tax map ��: � -� % nship; ' ot ��:
Subdivision Name:
Directions to property: State Road �� & Road Names, etc.
i�-c/ i . � � _ . � _ _ � / .e- rA—i .�G � / -s'�� 7 .�Q.1�
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6. Permit req�uested 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 adjoin
11,
public? community? spring?
g property?
If so, identify location:
Type of structure or facility: roposed: v Existing: •
Type of dwelling: House: Mobile Home: Business:
Type of business: Number of Employees• .
Number of bedrooms: Garbage Disposal? Yes ho
Basement? Yes No If 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 bf issue. Permission is her y granted to
enter the property for the evaluation. G.S. 130A-335(F)
_ (
Si e wner or Authoriz d Agent
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Permit Issued �
Permit Denied
Plat Observed
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I�ACTORS - SITE EVALUATION AREA 1 AREA 2 AREA 3 ARF� 4
1. SLOPE (X)
. SGIi, TEXTURE (i2-36 in. )
(Sand}�, loamy, clayey,
Note 2:1 clay)
. SOIL STRIICTURE (12-36 in.)
(Clayey soils)
4 - SOZL DEPTii (in. )
.5. RESTRICTIVE HORIZONS (in.)
(Impervious Strata� rock)
0
SOIL DRAITIAGE/GROUNDWATER
(bcternal & Internal)
SOIL P�RMFABILITY
(Percolation Rate)
$ . OTHER (specify)
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9. SITE CLASSIFICATZON 1
(See below) S � v
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECO2-RgNDAT IONS / COMMF�ITS :
S:�:TE CLASSIFICATION DIAGRAM (Ynclude: Sof.l areas, property lines. roads, streams, gulZies,
c�et areas, fill areas, wells, water bodies, slope patterns, etc.)
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308.42'
S89'32'28"W
190.34'
IS S89'32'28"W IS
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TOP FARMS, INC.
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200.40'
S89'32!28"W
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199.60'
IS S89'32'28"W
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IF
CONTROL
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Amount paid (G� ,bD
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R'eceipt .li 4
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� Date
Improvements Perntit.(Established/Recorded Lot) _. Reinspection of Existing System (Loan Closing)
ImpFovements Permit (Unrecorded Lot) _ RepaidReplace existing Septic System
Impsovements Permit (Mobile Home Replace) _ Pertni[ for New Well
ts Permit (Addition)
lace Exis[ing Well
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1. Permit requested by: .
�wner/nrosDective owneE
ome Phone #:
usiness Phone #59�=2z57
Name and address of current owner:
Description: Lot size:
Tax Map#: � ..�- a `�
Parcel#: � a �
C�7
. Directions to property: State Road #& Road
�
7. Dimensions or Proposed Structure:
Width: ^� `�
Depth: 2g "� "
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?
9. Water supply ty pe:
private �public ❑ community ❑ spring ❑
Are any welis on adjoining property?Yes ❑ No [�.
If so, identify location:
10. Type of structurelfacility: Proposed: OExisting: Q
Type of dwelling:
House: ❑ Mobile Home: C� Business: ❑
Type of business:
Number of Employees: �
Number of bedrooms: __— � �
Garbage Disposal? Yes ❑ No 0
Basement? Yes ❑ No�[ If so, # of basement fixtures:
6 Number of occupants or people to be served: �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED ST1tUCTURES.
I hereby make application to the PersOn COunty Health Department for a site evaluation for the on-site
sewage disposal system for the above deseribed 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 proper[y 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 [he date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
Signca Owner or Authorized Agent
• ' '- �♦
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Person County Nealth Department
Existing Sewage System Report For: Mobile Home Replacement
�ddition
Requestee: ��ii C� ���.�_ Home Phone#
�$ ( ��.���fl� (%�� Business# ��cj7
i� v�.v.�7� �/Ga.7573 'tax Map# 27 a��
Location/Uirections: �SO VV TI�- c�(°?�'l/� ��/ %1 5�G(� KSd/
��c._.. ,�6�"-� � � ��� � �g I
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Original permit Located �/
Septic System Uesigned �or: ^
Kesidential V I3usiness Other (speciEyl _
# E3edrooms � # Employees Other _
Uate lnstalled % -�?-95 Water supply ���i'�
'Pype ot System
0
Nitrification Line � /�v �� � � -
Tank Size
Certified Operator Required --
I v //T
On site wasL-ewater disposal system showes no visually apparent
malfunction on ���( � L J
Yermission is granted to: � n� a�-P�� � ✓� �
According �o the attached site plan.
Comments:
Environmental Health $�C..
����(��
� DATE