A27 237I ,`�r
Site �valuation Application
Fee Collected YES V
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Date:
NO
APPLICATTON FOR IMPROVEMENTS PIIiHIT
1. Permit request�d by: owner/�rospective owner: J b,
/� 2 agen,tj•
Address : l' '� • 1%�' �J �64 �p7t �jb i� ,J� ��'• aZ i
Home Phone �� : ,>�` 7�2`��9 Bus in s s Phone 4� :
2. Name and address of current owner: RJ_6�
3. Property Description: Lot size: l�jZ�___
�O�w� c.�
4. Tax map 4�: Township: ��/l/� ljl `�
Subdivision Name: Lot ��:
5. Directj.ons to property:, State Ro�d �� &� Ro�d Names, �tc.
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6. Permit requested for: New Installation: � Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served: �
/ / � �
8. Dimensions of Proposed Structure: Width: (� a Depth: �.7 �
9. What type (if any) additions, expansions, or replacement is anticipated to the struc-
ture or f cility hat this sewage disposal/ system is intended to serve?
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10. Water supply private? � public? community? spring?
Other source? (Specify):
Arf there any wells on adjoining property? �'jp If so, identify location:
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11, Type of structure or facility: Proposed: `� Existing:
Type of dwelling: House: � Mobile Home: Business:
Type of business: Number of Employees:
Number of bedrooms: � Garbage Disposal? Yes No
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 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 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 o'ssue. Permission is hereby granted to
enter the property for the evaluation. G. . 30A- 5(F)
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/S gned Owner or Authorized l�gent
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i�ACTORS - SITE EVALUATION AREA 1 AREA 2 AREA 3 AREA 4
S S S S
1. SLOPE (X) �D` �� US US PS
�T
2. SGII. TEXTURE (i2-36 in. ) S S S
(Sandy, Ioamy, clayey, PS � � PS PS PS
Note 2:1 clay) " U U U
3. SOIL STRUCTURE (12-36 i.n. ) S S S S
(Clayey soils) US ��,(Z US PS PS
�J U U
4. SOZL DEPTH (in.)
.5. RESTRICTIVE HORIZONS (in.
(Impervious Strata� rock)
6. SOIL DRAII�IAAGE/GROUNDWATER
(F�cternal & Intetnal)
7. SOIL PERMEABILITY
(Percolation Rate)
�,s� �esS -� ps
U �� U
S S
US �v n e Us
S S
PS � o ��Q„ S US
� i � �e
$ $
� ..� A'� US
s s
s
PS
U
S
PS
U
S
PS
U
$
PS
u
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PS
U
S
PS
U
S
PS
U
$
PS
U
s
$. OTHER Cspecify) PS PS PS PS •
U U U U
9. SITE CLASSIFICATION �
(See below)
SOIL SERIES
S- Suitable PS - Provisionally SuiCable U- Unsuitable
R ECOFiMEI IDAT IONS / COMMIIITS :
S�TE CLASSIFICATZON �TAGRAH (Znclude: Soil areas, property lines, roads, streams, gulZies,
Wet areas. fill areas. Wells, water bodies, slope patterns, etc.)
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SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area a c e Size of Tank �i7C3� <a��c� -�
SFD Mobile Home Size of Pump Tank ��/i-�
Business # of Bedrooms�_ Nitrification Line �/7 �X.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 '�r�t�fid�jd u�e ch�ged. �L
Well and Septic Layout by,
Comments:
ell Permit Paid
Installed by rn � �u� �5 Approved by
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SYSTEM SPECIFICATIONS
3ividual_�Semi-Public Required Slab _
�blic Replacement Air Vent
te Approved ✓ Required Well Log
ell Head Approved Well Tag
�outing Approved
Comments:
Date --�S Installed by �l![.'�YI S Approved by!
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. The
environmental heaith specialist is not responsible for false or misleading information contained in the application. The emironmental 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 to function satisfactorily in the future or tha[ the water supply will remain potable. c:�amipro\permit.sam 01/95 rev.1.0
4
�-� ''� v P�RSON COUNTY ENVIRONM�NTAL H�ALTH ��. �
�.Date: . y�g- 4 �
Owner: �. � �
Location/Directions:
�ub�':vision N�ulZc:
Drilling Con�-actor:
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W�LL LOG
,
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SR#
Lot #
Distance from_Nearest Property Lulc c.,.s Distance from Source of �
Pollu[ion o c1 ,,�s
Total Dep.th:� 1.�� Ft. Yield: � GPM Static Water Level_,�� Ft.
Water Bearing Zones: Depth _�TFt. Ft. Ft. �t.
Casing: Depth: From�_to �/ �/ / Ft. Diameter. �� Inches
TYP�: Steel � Galvanized Steel .�
If Steel, does owner approve: Yes No
� Weight: /3 Thickness: , eight Above Ground: / si Inches
Drive Shoe: Yes �No
Were Problems Encountered in Setting the Casing? Yes No
r n
Ic yes" give reason:
Grout: Type: Neat Sand/Cement � � Concrete �
Annular. Space Width 3 Inchcs
Water in Annular Space: Yes ��" No �-
Method: Ptunped Prc:ssure PoLreci ��
Depch: From �—to d�_t=t.
Materials Used: No. Bags Portland Cement�_ Weight of .1 bag r f� lbs.
If mixture (sand, gravel, cuttings) - Ratio: �-- to 1
�ID Plates: Yes v No � � � �: �
� 4 x 4 slab Yes �� No
_ . DRILLING i.CXt
Fram I To
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Formation Descri
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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 COUNTX HEALTH DEPARTNiENT:
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c�/�-Cl � . �.. �.�'��'s`'
Signature of (,ontractor Date
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