A35 151.; !�•son Count
� Sev�age System
Date: �SZ�ZThis Permit Void .
Owner: ��1� v' /
Location/Directions:
•
y Health Department
Improv�ments Permit
5 Years Permit # �- � a �
i✓P�-, S1t# /�3'7
Subdivision Name: Lot #
Lot Size: �• o � Type of Dwelling:
Water Supply: Private: P.ublic: Community:
Bedrooms: 3 Garbage Disposal
Basement Basement Fixtures
INFORMATION CERT'IFIED BY
Environmental Health Specialist• o er or S��u�e
REPAIR: REE UATIO :
Size of Septic Tank: �D� gallo � Size � Pump Tank: (
Nitrif'ication Line: _T�_,
Depth of Stone: 12 inches -
Max Depth of Trenches:
Altemative System: Conv. P�mp LPP Pump
Remarks: /1. .�:. 1. o-�? z5�� L�( ��f'
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--------------------------
Date Well A ved: �'� " � '��
ppro Well should be 100 ft from any sewer system
BY � Environmental Health Specialist
Date a e s Appmv G���.,���
BY Environmental Health Specialist
�� ��� CATE OF COMPLETION :--
Contractor. � 1'�l /'s�? n..�, F `�
Sewage System location, installation, and protection must meet state and local
regulations. 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 tank ancl
nitrification 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 pernut is subject to revocation
(G.S. 130 A-335F)
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
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Date: �_� SZTt
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I.ocation/Duecuons:
L�� l
County
Weil
Permit Void A
W � ��
Heaith Department �
�errriit �
3 Years
SR# I33 7 �'
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r./l rt f � .7 v �
Subdivision Name: � ''' Lot�
Drilling Contracwr.
WELL CONSTRUCi'ION
Distance from Nearest Property Line Distance from Source of
Polludon
Tatal Depth: t Yield: � 2— GPM Static Water Level FG
Water Bearing Zones: DeA� �F� FG FG �.tFt.
Casing: Depth: From v to �� FG Diamet�r: (n " Y Inches
TYPE: Steel Galvanized Steel�
,
ff Steel, does owner approve:� No �
Weight Thiclrness: Height Above Ground: Inches
Drive Shce: Yes No
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason:
Grou� Type: Neat Sar�d/Gement Concrete
Annular Space Width ��� Inches
Water in Armular Space: Ycs No
Method: Pumped Pour�
Depth: From _� to e FG
Materials Used: No. Bags Portland Cement Weight of 1 bag
lbs.
I HE�
THIS WELL WAS CONSTRUCTED IN
FORTH BY THE PERSON COUNTY H:
ff mixnue (sand, gravel, cuttings) - Rario:
ID Plates: Yes _� No
4 z 4 slab Yes ./ No
U,je�,� Vv�vs�" �e
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-f �►�� dy�,h (/'��p �,- ;
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D THAT
WITH RE ULATIONS SET
NT.
� `143
Date
� �alN/�Z
e Date Issued
� .
�v c�-/'�•�r h t�,/ i��c� �.� Sanitarian's Signature Date Completed
�cet�h w�ll locarion on %verse �ide. �.s C.cf10:� �
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Aaalication Date: �I -IR`-do ��� Tax Ma� #: �S ' : .
Amount Paid: 15b.0o - 1 �'
Recei ' �9�'� Parcel #• -�
. _,�'?_ � ���� �� �/ / - %Z�CX�f'- .
- -_ �C��T1�T�C�
• � a:a.vsa-.ma-a.�a.es:a�ml1 IFao�.7L�]Ea `i�`�� r ���� �/��
APPLICATION FOR SERVICES
�Permit requested by: �t�gent/prospective owner): � 1��� Lc/1�!Q :�� /�
Home Phone: � .�l Address;/ � I "
Business Phone: • �'�'`� '� � 7 7
2) Name and address of currer�t ownec �
� a��
�- � ��o , �.� �
3) Property Descriptic
Directions to the pro
4) proposed Use and Structure Description: answer each of the following questions:
.... a) Proposed _, Existing � Type of Structure: /��i Width: Depth:
��' b) Number Of Bedrooms: - Number of occupants or peopie to be served: �,
��� c) Basemer�t: Yes � Will there be plumbing in the basement? No
. d) 6arbage Disposal: Yes . No ✓�
5) Water Supply Type: Private _(new _ or existing�, Public . Communiiy� , Spring _
Are any welis on adjoining property? Yes No _ If yes, piease indicate approximate tocation on the
'site plan.
6 Does your pr+operty corrtain previously identifled jurisd[ctlonal wetlands? Yes_ No '✓�
PLEASE NOTE THE FOLLOWiNG:
➢ A PLAT� OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPUCATION.
➢ PROPERTY UNES AND CORNERS MUST BE CLEARLY MARf�D. -,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAi�D OR FLAGGED.
➢ THE SITE MUSfi �E REi4DILY ACCESSIBLE FOR AN EVALUATION 8Y THE HEALTH DEPARTMENT
STAFF. � . �
I hereby make application.to #he Person County Health Department for a site 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 ta be placed on the property. I understand if the site is altered or the intended use changes, the pertnit shall
become invali�. �
l.egal
-/ -O
Date
PCND, rev. OBJ27/02
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.��rn,�nir►a[Dmn.�r3rn.��rn.�.�n.� �c�.�a,���ih
Building Additions/ Mobile Home Replacements
Tax 1VIap #: a 35
Approval Requested for:
Parcel#: �1�� ��
x Mobile Home Replacement Naw �`''^^'-
Building Addition
Applicant Name: ( �„rz, L�r�, . �'r
Address: la9y M�6� 1M�'tt �
tZo,��� �c. a�s�ti
Phone #'s; �o - S�s- a 15 3��
Permit Located: Yes ✓ No ( �
Installation Date: �q�3 Design flow: 3 O(gpd)
Current Contract with Certified Operator on file (if required): nG•
Water Supply: ✓ Well Public or Community
Wastewater system shows no visual evidence of failure on: �-1 �.-c�c,a (date)
(Applicant's signature if site visit is not required)
� � •.• • s . L_� '3 • ... _l�
at • •
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Addition/Replacement Approved
I C.. � �- I9--o�
Environmenta.l Hea th Spe alist Date
11/15/OS
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TE��y-�,r,,,.,.-„ ����.11 ]E3[�m.Il�l�.
5I'I'E S1�E'I'CH . � 5' i
Name ��YL/ (�l �_ Tax Map # �� .Parcel # ���
Su division 122 �Co lLl:�1( � Section/Lot#
�� _ ��
Autho�iz d Sta Agent � Date
System components represent upproximate �contours only: The contructor must, fTag the system prior to
beginning the installation to insure that j�ro�ergrade is maintained �
��cale: �01- �o�—
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PGHD, rev. 09/12/01