A35 102� ' J
,� . .. � z
` ,� �erson County Health Department �
�
���ewage System Improvements Permit
Date:�c;rf �_9�This Permit Void After 5 Years Permit #�1"�'?3S�
Owner: � G n _� i� YS SR# _�� �
Location/Directions:
Subdivision Name: Lot #
Lot Size: Type of Dwelling:
Water Supply: Private: Public: Community: �
Bedrooms: Garbage Disposal
Basement Basement Fix �
INFORMATION CERTIFIED BY � -
Environmental Health Specialist: ow r or represqn�acive
REPAIR: REEVALUATIO : ���
------- -----------------
Size of Septic Tank: gallons Sjze of Pump Tank:
Nitrification Line:
Depth of Stone: 12 inches � i S �
Max Depth of Trenches:
AltemaUve System: Conv. Pump LPP Pump
Remarks:
--------------------------
Date Well Appmved: - -�� Well should be 100 ft� from any sewer system
BY Environmental Health Specialist
Date Se e ste A roved: — �
BY nvironmental Health Specialist
ERTIFTCATE O COMPLETION '
Contractor. �
Sewage System location, installation, and protection must meet state and local
regulauons. Septic tank 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 fank and
ni!rification line must be inspected and. approved by a member of the Person County
Health Depaztment 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)
I.ocation of sewage disposal sewage system sketched on back.
(OVER)
�
�
�
�
�
.�
..T— ' - '
, � � �Person County Health Department
' Lj Well Permit
Date: �'��7 his Permit Vo d After 5 Years �
Owner /�i r� '4��j J'yr' � _S' SR# / ��
Location/Directions:
Subdivision Name: ' #
Drilling Contractor:
WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollution� �j - - '
Total Depth: FG Yield: ` GPM Static Wat�r Level Ft.
WaterBearingZones: Deptly_�•�t�FG ��Gf j�Ft.
Casing: Depth: From L.,.� to L• �' Ft. Diameter: �� ��� Inches
TYPE: Steel Galvanized Steel'�
If Steel, does owner approv �No
Weight: Thickness: Height Above Ground: Inches
Drive Shoe: Yes No
Were Problems Encountered in Setting the Casing? Yes No
If "yes" givereason: �i
Grout: Type: Neat �a�j/Cement Concrete
Annular Space Width �- Inches
Water in Armulaz Space: Yes No �
Method: Pumped,�_ Pressure Poured
Depth: Fmm to �
Materials Used: No. Bags Portland Cement Weight of 1 bag lbs.
If mixture (sand, grave , cuttings) - Ratio: to
ID Plates: Yes No
4 x 4 slab Yes—�^No
b
�
cu
�
'ti
�
Z
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT �
THIS WELL WAS CONSTRUCTED IN CCORDANCE W1TH R ULATIONS SET �
FORTH BY THE PERSON COUNTY H H PA MENT. �
. 3 I`� q �
Sig e Co tra or ti Date
.� � � /3_��
'ans Si ature Date Issued �
Sanitarian's Signature Date Completed ;
Sketch well location on reverse side.
�NQTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
� supplies, 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.
. %1 r' _ � �,_,-
(1)
�
��'1�.7/;��i
� I I I I; I I nl �_d_L_ I�;
�
� N��
� � �+--�—�' � �� i� � � � ��
-7-;-r- �7-,-r- ��r--r
A���� �: � i � �-�o
Amount Paid• ► �—
�,�_��
Ar �
// �
2 � �/�
. ��.�
C� $
�� �-$
� � � .
� 3'7.3 ��° ��!C�
�-'-- �S .
� a. I%�erson Couniv Health Oeoartment
C� �$��� 0� �`1i Errvironmentai H�itl� Se�tton
��.� �p
' � �ec1 ' APPI.1CA710N FOR SERVIC�S
�� �p �: �d- 35
t�: OZ
�� Home Phor� .�(cl p°cliw � Qh� vV !/� S
Bt�s�teas Phcne: o o •
2) Nams and address af cunerrt ow�: � ��'] �� v-C .
��
$� P{q�� �pil; 1.ot glZa ,� ' Q��'TOM�pC •` U+� n� 1n� � 4,,... t,�.Y/`� R.� 1.G /C G�'
Dlr�orlBfiDttUe propecty$�u�CCfl �P.e,o��'��Dl nl/�CX �. � h a y oh r.C��.at��C
4) Propossd Use and Struct�ue Deaer�p8on: anawer ead� of the foUawin9 �
� a) Ptoposed 4 E�ds�g �
b) Stldc B�t 4 ModWa� Singie Wide Q Dauble 1Mde 0
c) Ntunber of Bedncome: � . . c� Number of occuperrts cr people to 6e senied: �
e) Bassme�rt Yas �. No �!f yes, # of basement �u+ex
� Gerf�age Dts�osal: Yes 4 No 18. �- 7$ l t I
� D(men�na of Propoaed Strudtue: Wldtl�: �Qepfh: � 4 .
�� s�Phl �: Prhrate�(new � ar �9 �. Pub% q Cammuniiy �. Sprin9 0
• � Are any w�eQs an adjoin�g p�operty? Yea ❑ No � tf yea, bc�tlon
Bi Nd1c�a D�ired Sy�m 7ylpe: (�Yaiems can bs ranioact in or+der cf yotar p�efeerencsj
Cornn�l _MocS�ied Comerrtional _ A�ite�nai�re Innovative
.Dther (spedlj�):
CLEARLY 3TA1� ALL CORNERS AND UNES OF THE PROPERTY,
3TAKE THE CORNEiZS OF ALL PROPOSED STRUCTURE3.
PL�A,SE ATTACH SURVEY PlAT OR 31TE PUW TO THIS APPUCATION
'� C� 1.1
� ,.� a d � csz
. `}-� til e-e.�
o � l o t—
! hereby make appQc�lon� to the Petsan County Heaitl� Departrnerrt ior a s�e eva�atlan inr the on-ait�e sewage dispasai sy�am far
the above-d�ed property. i agnee that the � af thls app�r.atton a�+e true and represerrt the ma�drtwm �es ta be
placed on the pmpetiy. I unders�and if the sibe is aibeted or the intended use ct�anges. the permit sheil become irnraiid 1 un�d
that as ?iPP��k 1 am ra�ponaibie for iderrt�in9 ��9 P��Y W�es, comers and maldng the site aa�b�a fior the
personnel of the Persan Ca Heatth Depsrtment to c�►duct their evaiva�ona I understand that i am respons�le for notitying the
H ent ifi my contains any we�ands as designated by the Army Corps af Enqineets, .
° C . � � �- - a.v
. � � �e . �a -
PC}i0. tBv 10f12199
, �' �, .P�rs��a C�t� �ealtla. �Dapact�rdeni __ ... . � 3 .�.
. ' � � �r�t�men� D�esi#h �eci�on T���p �
. _ . . P�rr�d � � z
� � Si�"� Si�"t'GH � . . . . _
. „ _ -..
- - -= �ar� �� � ��rS � .
— e SuhdivisioNSec�foNLaf#
, . �- � .-� -
: Authorized Stabe Agent Date
���� �pP�ud�°�a c�t°roa °� T�re cs�or ra�t, fla� the a�
� p�er �v �g dfrs iti�la�w � mnme 11t� Pr'+�ea' Sr�fe is �
,
; � �
Ke�� sep hZ srs
� �o� ,*�..;.,,,�r,.. ..F-,.,.-
`�`Y P�P`��,j• �;,.�
o�
� \
ConVeh , �
�ys���'�� �,fi,��
i 2 1uc�; �u� `i'Y'ei^c
� Ini 1� deI'-�-� �.
�pOD$ --
�61'>V eyy'�� �, �'
+�e��. � r-
� �
rc.e�
—_
�
Z2a, �
� �
Scc�e' —� 1= i�n n t�--
. - �
6
J � �
� w �� ��N,�, I � �
� a r� �� � cover- utr
. � ,�`'
-}�a ��� S� trec�' oV �r P��� �'P S-2� � L
a Y� _ ,�- .
� Y�9�•1� Ul.$ c�'►�. o��. �ttiq� r� L.e-`rS I QJV � I �
�J �
�eep �''P���es af �,��e r- ��� e � .
.-�,�1ow��,.� �o�fiw�-, .
��
�ecp s�� fi � �- ' \
�Sry►tini�••un. �ro�rr�
�� r /� ry
I•VC ML[n Q h
J�
�_1�" _�
2 gr .
'b6, le.
c��-L1 �4'Y�.
� ,
��xisf;�9 5�� He�ess �Se.,.e��--
—.�
-t�s
�_
--__�
{� �,
. . ----•• -�- - --... __-.------ ••- .
` ��1'9�14 �l1:i11f �@��l. �6Q1A'�i16�9$
' . � � �s�vir+�rameni�i Hestth Sec�ion Z8���1ap �: f�-3S
- _ . . . � � � P�si � � � /a�?
� Si'�'E Sl�iCN � _ . . . _
_ ...�a%� �� i V`� f�S �
Applic�n�s Narne S�divisioNSec�ioNL��
. Author�Zed Sta�e Agent 0� � ' .
,ry� �'+ePr.c�rt � c�t°ras ar�'. T�re � m�r, flae the � .
p�lo b�r�ire �t � �u+� r�t�S� is �
�
J
�Xi51'�v.Jc � BY Salf �uh
Vq�J�
. ntob;le � �� ` o o ._��
_ F ,-
,
(�ou5 Z. �-
`s:re
3 0��
�
� f I
► c��- ,�-� s�.�� y �,�
�,,,,..�i' � w'S -�,1) � �Gc �. - -
d ��e�s�Qv.
...�,- �l o r✓ ' x� e cC.: � ��
2. 14c�� ���f X3r ��'� %�� mun. ��� Cah,, �
� �
L..s��� af ,� ro� er r�e -�<<cwl�r �.
� ,'n�e��eve.��41SLr� is ►^ hYi�YE,� '�Y ing�+l�s7io�
., , �n 9 �" ?�G-�-
�Ol r Gi.dG�r�Cohaj s'oc�l C'OVG'+' 15 Y�P.�il �"� �VE►�
«
�,�,tl �-e ol c-�►I h.�:'� ld� ah d-�: ep �� 3- `.�'e¢ f�,1„',hk,,,.
b e y c,. Gi `i1''e h G�es v>. �1 �l S'r' a�� s
� �- _..-
t t/
Sc�: _�,� r�T TO S�A��
c
�
0
�
ii3i
0
Tax Map tf: 1T-3 � p
AppUcar� �i �'
Locatlon: 0 � %
• ► r
Townshlp [n Hi �
PIN
Su6divislon PhasQJ3ectlon l.ot�
Improvement Permit �
New �ddition Type of Structure � b�- �+� e� � Water Supply We ��
# of Occupants # of Bedrooms � Other
Projected Daily Fiow: ,� g.p.d, Pe� Va i
Proposed Wastewates S�em: SL�R%ocJ a
Proposed Repair. �'!it /(oitJ D a�c' .,ve:z f��
Permit
V�
Owner or Legal Represe�tative
Authorized State Agent:
�
System Type,_�.
� Years Cl No Expiration
�r,a i
^ ,�. � �% � /►
��� � $�=/$(CGs1- s m;^ �ror►, �G(� I�in.( �, / i
-�F� u r. n�a/� o �, Q v�d �J
'N ..Ll�$��ill G�.T I"0 ►� YL�•C! � ln � n�uY".
!ign ture: � Date:_�-�' ��"' ��
� Date: � � � � b 1
The issuance af this pertnit by the Health Department in no way guarantees the issuance of other pertnits. The permit holder is
responsible for checking with appropriate goveming bodies in meeting their requirements. This site is subject to revocation ii
the sita plan, piat, or the intended use charyges. The Improvement Pertnit shall not be af�eected by a change in ownership
of the site. This permit is subject to compliance with the provisions of the Laws and Rules for Sewage �reatment and
Disposal Systems of the North Carolina Administrative Code.
Wastewater System Description: S�� ��a � �� � Coh�Es '�o� 1Nastewater Ftow: ��d s�,p.d. Type: '� _� •
Facility Description: a �• �5 ► d ew"� � o�-i New� Repair ❑ Expansion ❑
Basement? O Yes o Basement Fixtures? D Yesy�No
Wastewater Svstem Requirements
Tankage: Septic Tank size O O gal. Pump Tank size
TrencMes: Total length . 3� o ft. Trench Width 3 ft.
— gai. Grease Trap size gal.
Total Area D sq. ft.
Max. Trench Depth: � in. Aggregate Depth:�,� in. Soil Cover. � in. Trench Separation �ft. on center
Permit Expiration Date: -<3 - D� -,1� (�� a.�o�r ��o� i S�'% .
Authorized State Agent Date: :'`� 'v �� C� ��'�' rC°�'`; ��
*See attached site plan and addendum pages for additional permit conditions. ,
The type of system permitted O does ❑ daes not differ
speciflcations of this permit ��
OwnedLega! Represerrtative
type specified on the appiication. 1 accept the
�
`�� Date: O� � �"'� 0�
System Type (in accordance with Table Vaj • �
This system has been installed in compliance wilh applicable idorth Carolina t3eneral S�s, Laws and Rules for Sewage Treatrnent
and Disposal, and all conditions of the Improvemerrt Permit and Conatruction Autho�ation, issuance of fhis permR implies no
guarantee that the sysbem insta(I�d wiii functton prope�ly for arry given period of time.
Authorized State Agent
Date
PCHD, rev. 03/07101
.
�.�, ; , �� ���bJ' ��
` v � � � ����
I� �� a- � �� � �. ��.Il. IL� � .�. ]1 �I�
�x M�p ; F�rcel # �
Subciivision
Ph�se Sectio�i:`Lot #
# of Bed�rooms
Applicant: (�A n �� � V�fS
Locaiion: R9 1�Y��n�,/ /1�, �
,
- erat��n er i�
System Type (In Accordance With Table Va):. �
THIS .�YSTEM 0-lAS BEEM li�lSTALLED IfV COtVIPLIANCE WITH APPLICABLE NORTH
�i4ROLINA GENER�►� STATUTES, RULES FOR SEWAGE TREATIVlENT AND DISPOSAL,
AND ALL. COt�DITIONS OF THE IIUIPR�VEMENT PERiVIIT APlD CONSTRUCTI�N
AU�',HOR�t�P�i i �
Autt�or�`zed Sta�e Agent
Installed By( � n,�_ .,�;�,�
n, _ 1
0
d
��f� �'��- -
Date
Date: .5��3l�DS
. ti� .��.
�o� � S.LJ.
, ,�a .
�g' �
��� ��a
_ �'� .a
^
� g�
�'
�
L9..- I bS
�2— q�!
�3'� 22
-,320�
PCHD, rev. 07/29/Q4
�
�E�'�1C °i'AN� I��P���"��� C�E��C�.9�i i�'y�e 68 � 1�)
Tax Map # A3s Parce! #J b2 Sys�em Type (Tabie Va) ,�
Owner/Applicant Dan �l,�v _r� Subdivision
Address/Location $� /Vl un�lc�� , Sec/Phase Lot #
State�lD/date �g-32t
Capacity P7"5-►aad
Tee and Filter
Baffle
Sealant
Riser (ifi applicable)
Tank Outlet Seal
Permanent Marker
Pumu Tank
�
Waterproof /Sealant
Riser
� Purnp
Checic Vaive/Gate Vaive
and a
lil!$1�6/��$� NIfiB$1C��IOB"9 Lli1�S
-Z - � Trench Width � , ,� ft.
� � Trench De th - in.
� Trench Len th �Zd ft.
Trench Grade �
Trench S acin
� Rock De th and Qual'
Dams/Ste downs etc.
Pressure Laterals
Hole Spacinct
Rate (gpm) �
Approved Pump Modei
Blocic Under Pump
Pump Removal Rope/Chain
. ��Distribution. System
Serial Distribution
ressure ani o
Low Pressure Pipe
Aoqr. Pipe It�lateriai and Grade
Sleeve
Requi�d� Setbacic�
From Welis "
From Property lines
StructuresBasetnents
i c es rainage ays
Surface Waters
Pubiic 1Nater Supplies
Vertical Cuts (>2 ft.)
Wa#er Lines
Vehicle �Traffic �
Easements/Right of W
Other
Easements Recorded
e i ie pera or on
Tri-Partate AQreement
Coenment�
pct�d rev. 31'13/0�1
Person County Health �epartment
�xisting Sewaqe System Report For: ✓ Hobile Hom Keplacement
Addition �wii�, itiLod�r f-��e, '
Requestee: ��n �h�`'��^5 Nome Phone# S`}7-36�1&'
�q /%%urtdc�y_ f�d. Businessn "S�n�e-
/�eXbe� /�C �-7 S 73 , Tax Haprt l�3S- !oa
Location/Directions: (.�u� �� � � �cG�eeS/�{1,;l! 'l� .
_� _�GttiO�a y f�4 �`� 9'Yztv�l d��'ve o� � �c-7� rl�Ce.��l
lRn�' � ' �•l
P�L✓�/I"�tr►C� .
Original Permit Located yes .
� ,
Septic System Uesigned �'or:
Kesidential `� F3usiness Other (specifyj
# f�edrooms � - # �mployees Other
Uate �nstalled aa .5� Water supply �e `�
Type of System C-Oh►/ei�,"fio�
Nitrification Line 3o�r x 3/
Tank 5ize �Dd� 2�X -
Certified Operator Required /U� �
. On site wastewater disposal system showes no visuaily apparent
malEunction on 3- 3� - � �
. Yermission is qranted to: ��r�i /1{�� � f GlOhu�w�o-n�f s�7;c �,� �
- la'' r„ax. �hc� G�C� �i. -i�,c! „ Ua�ve �. �``��1�,�;a.�a/ �' ccv�v-rr���
According to the�at�ached site plan. ��
Comments: �L�e YIC� .1.I• � S��C S�'�%� -�iar 4��Cdi�/,�a�
t Y�-�-or h��1 I r D►� �
Environmental Health $�C.. �
� ,.:'4�;;,...
. . . �i'3'�r?�.:.
6
0
�� S�f ���.� �� o� ao � �
;'� _ � --
~ =`L �;a : . 0 0 pVC4IDull�3 l�l�"�n(j�(j W (, 1� � �! 1 �(/ �y 1��
.:�� ��:� �����..... /
�������,.;Y„ ��.-�.�:� ����:.��� o� o� 3� 3- O�
o��: ! S hf
Location: G� t�
Subdivision:
Grout Log
Tax Map .�
������5 ��"i1
Lot #
. • Well C straction
Distance From nearest Property Line (Minimum 10 fee� `
Distance from S,�P c System (Mini um feet) �J
Total Depth�/ ✓� ft Yield: � GPM Stafic Water Level: _��� ft
Water Bearing Zones: Depth ft ft ft ft
r�z
Casing: � �
Depth: From �_ to ,� ft. Diameter: _�� in
Type: Galvanized Steel
Weight: Thiclrness: � Height above Ground: � in ; � /
Drive Shoe: Yes No Any problems encountered while setting casing? Yes �No
If "yes" give reason:
Grout: " . /
Neat: Sand/Cement Concrete GraveUCement V
�. Annulaz Space Width � inches Water in Annular�P ace Yes No
Method of Grout: Pumped Pressure Poured [/ Depth to
Materials Used:
No. Bags Portland cement � Weight of 1 Bag � Pounds
If mixture (� gravel, cuttings) —Ratio to
ID plates: _ Yes _ No 4 x 4 slab � Y _ No
Liner:
Depth:
.. ,..
Date Installed: Grout:
Drilling Log
Ft
Installed by:
Location Drawing
Fr m To Formation
(�✓ L'1� �
`1�
2
�� 5� � `�, �u �� �y �
�_
- ��
��
. �
I hereby certify that the above infom�ation is correct and that this well was constructed in accordance with regulations set forth.
by the Person County Health Departmen� `
Signature of Contractor�%i� ID#��� Date � G�6
Pump Installment
Pump Installation Contractor: /J�f� {��✓� I � �� r� i�' �/Gstate Registration Number: ����
Pump Depth: ft Stat�c_Water Level: 2 S-- ft l
Pump Make & Model: ��_� c�� G��� Pump Size and Rating: l�hp �� gpm
I hereby certify that this pump was installed and the well head completed according to the Person County Well Rules in effect
on this date and that a copy of this record has beeri provided to the well owner.
Pump Installer Signature� �--�W' Date: J� �� 6 PCHD rev O1/27/04
��SL3N C�UNT'! E3�I�/iRONME�ITJ�L h1E:41' TH
Pi�,S� S� .A7'TAC9�E�D PU��i Ft3R WE�L SiTE tA�Y�UT
��� � A-3S� �.,� �r-�- l02
s�a �nh��ho, r►�
zoo�oo -
� �>y `�"'��V�C+'.S .� � .
�„� g� r�►1 u r,.d�� � - � � � -
� - � . `°C_ -
- . Wel1 Permit � -
� Tvae of 1Wa�er Suoola: �nd'nr�ivai Commucuiy . PubGc
- ��
�-- - � � - . '. �
ReQuiremani�:. . �`'
A' � .
_ Site APproved bY � -3 � �' `' `' . � �,,�
. Groufmg Ap roved by. CS ��--� -�� �` ✓
,,,,d, �, �<- ,,� : . ,� � � J
}Nelt T ' • � 0
A� Vent ' - .
Hose eb -
Cocuxete �
_ J � .
t�.
� w�n o���: .�--
- . �. �
Welt App�oved By:
'''See Actiact►�d Sit+a Staafich*`
0
� 1Nells must be 10 feet from P��Y Mes.
WeOs must be 100 feet from septic sys�s.
1NeUs must be at least 25 feet fram arry. building foundation.
Other cond'rtions: . .
PC}-i0, rav. tUZ9lJ9 -
�
�
0
S'�OS� 1i Gv<`� ��• ��j(/f,�LS <�j�'f—�//�� , .
�` ��� ����� '
,��e� �� � ���5�0,������ .����,� w��
��� � � .
�ri � �'�,� ��.{ ,� �=°.�` � -� 3 ��,��s.
��� � ;
'��`� ;
_
' U'�' `�D �s.-� -�D %,.;..t ci�� lns� c�ti�^S �9�t�1