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�,4 Person -County Health Department
. ��°ewage -System Improvements Permit
Date: .���This:Pemut Void After 5 Years .. Permit #�1a��8�
Own�er. G r� r'j 1-� ; V e,�c
I:oc�tion/Directions: _ . _, SR#
SuUdivision Name: Lot #
Lot �Size: ' � Type of Dwelling:
\Vater Supply: .Private: ' Public: Community:
Rediooms: Gazbage Disposal
� Basement BasementFix ,. �- '
INFURMATIOIV CERTIFTED BY ”
Environmental Healih Specialist: o r or repre� r�ci�e
REP��IR: _ REEVALUATIO : �
Size i�f Septic Tank: gallons Size of Pump Tank:
Nitrification Line: /
De�th of Stone: 12 inches � Q p
Max Depth of Trenches: � � �
Alten�ative System: Conv. Pump LPP Pump
Remarl.s•
Date''�Vell Approved: -�.Well should be'l00 ft. from any sewer system
Bl'=- Environmental.Health Specialist
D1te Se e ste A rc�ved: - �
BY— nvironmental Health Specialist : .._._ �
TIFICATE O COMPLETION �' �`"
Contractor. + �
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Sewage System location, installadon, and protection must; meet state• and local �
regulations, Septic tank should be pumped out every 3 to 5 years and shall be maintained
tiy owner in such mannei'as nof. to cieate.:a ptiblic:health haiard: S'eptic tank;and �
nitrification line must. be .inspected_.and; app�oved by;.a.memb.ei of.. the. person Counry
Health Departrnent before any portion of the installatiqn is �covered and put into use: If �
the site plans orintended use change this permit is;subj�ct to;revocation. �
(G.S. 130 A-335F7 : _- ' �
Locadun of sewa e dis sal sewa e �
:. S Po. g system sketched-on back. • . �
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' :� �erson County Health Department �
�/ Well Permit "
Date: �-%7 i"s Permit Vo'd After 5 Years �
Owner. f�i r� �ye° ��" SR# � b
Loca6on/D'uections: I�
Subdivision Name:
Drilling Contractor:
. WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollution�� u --�'"
Total Depth: J w F� Yield: ` GPM Static Watgr Level FG
Water Bearing Zones: Dept}�_�tr�Ft '""�G i 1. _pt
Casing: Depth: From C� to G-�• FG Diameter C��� 9�ches
TYPE: Steel GalvanizedSteel'�
If Steel, does owner approv • No
Weigh� Thickness� Height Above Ground: Inches
Drive Shoe: Yes No
Were Problems Encountered in Setting the Casing? Yes No
ff "yes" give reason:_ __ �
Grout: Type: Neat ement � Concrete
Annular Space Width �� � Inches
� Water in Armular Space: Yes No �
Method: Pumped_8_ Pressure Poured
Depth: From - to FG
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
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT �
THIS WELL WAS CONSTRUCTED IN CCORDANCE WITH R ULATIONS SET '"
FORTH BY THE PERSON COUNTY H H PA MENT. �.
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Si e Co�tra or ti Date
, � _
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arian's Si ature Date Issued
Sanitarian's Signahue Date Completed
Sketch well location on reverse side.
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y� , A �rc�on Da� � 1 I-02 -00
Amourt! Pald• 0� -�O '—
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T� �p �: �- 3 �
Par+csl �t: � 6 �
Petson CouMv Heaith Deaartment
Errvironmentai Hesitl� Sedion
� APPLICATiON FCR SERVICES �
IF THE INFORMATIaN IN THE APPUCAl10N FOR AN IMPROVBYIEiHT' PERAl1T IS FALSiFiED. CHANGED. OR THE SRE iS
ALTEl2ED. TH6V THE 1MPROVBIIIE�IT PERMIT AND AUTHORfZATION TO (�NSTRUCT 9HALL BECOYE 1NVAL10
1) Fermit requesied (Ownerfa . awrro�; � � v�� S
Homs Phona � �� .5�3 "� — � � � Add�
8t�s Pitana: �o r+� -P � , c� .
a) Nams and address of carns�rt ownar: I a. ' �{�r -
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3) pt+pp6ily pe�ptl; !ot sizx � Ta�sttlpc • C UN n r`n� � G. �.,
Dtr+�ions t� the prope�ty (�ru�udj�e r�d names �d r�s� _
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4) Prapo�ad Use and Structurs Desqiptiott: anawer each of the foUowin9 q�tlon�
� a) Proposed q 6d�ng O
b) Stldt Bu�t ❑, Modutar �. ir�ie Wlde � DauWe Wtde D
c) Nwnber of Bedrooms: ,�, . . � Numbet of o�nts ar people to be ser�ed: �,
e) Basemer� Yes a No �If ye9, � of basemant �urex
fl Garbage D� Yes 4 No �� �
� D(m� of Propoaed Shuct�ue• Wldtlx � Depih: �Q •
3i ��PPhI �: Prlvate f� (new � ar e�(nA �. Pub6c 4 CammuniiY 4 5p�n9 ❑
� � Are atry w�elis an adjoining property7 Yes ❑ No � If yea. loc�On
��e Indica�e D�ir+ed Sysbem Type: (sya�ems can be ranioeo! in order of yotu p�sterencs)
�Convontlonal _Mo�#led Cornnat�tlo�al
-Dthx isPecsh►):
_� Innovativs
c�►�.v sra� aLL co��s nHn w�s oF TMe ��rr.
s�ra� TME co�w�s oF atl. �oPosm sTaucru�s.
Pl.�A9E ATTACtI SURVEY PLAT OR 31TE PLAN TO TH19 APPIICATION
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I hereby make appiir.af(on� to the Person County H�ith Depautrnent far a site evah�atlon for the on-s�e sewage d�posal system for
the above-deaaibed property. t agree thst the � of this appiication ata t�ue and represent the maximum fac� to be
plsced an the properiy. ! understand if the site is aibered or the inGended use rhanges, fhe permit sheil became irnraHd. l u�tai�d
that � aQpBca�rt, 1 am respona�ie for iderrtiiying and markin9 P��Y iine�, comers and maldng the �ie e�ii� 3or the
P�ne! of the Pers� Cowriy Heafth DeQsrtmer�t fo candud their evaivationa I w�ders�td that I am respor�s�ie far noh'tying the
artrnettt if m!► c�ins anY �n�lands as designated bll ��Y ����. .
.� . . . _ � ,� � .
�` . o Legsl Repteserrta�ve . Dabs -
PdiD. rav.10(12199
• PEi�SaN Ct�lltV�'l E�l�IROtVME�ITAL HEALTH
E� A►�'ACHE� PL�iV ��R St�IL �►REA e4iVD_SYSTEiVI LA►YC
TaxfNap�i: 3✓ Parcel#_-a�-_ f,�- •ownship �hYt �c2� � N. PIN
Aaa�� h S� i VG' j"S s���o� ��rs�uo�
i�cancn: � U"�Ct �OGlh vI
�o�
imt�rovement Permit
New Addition Type of Structur�e J�'"" (�-����`� Water Supply ��'
# of Occupants # of Bedrooms 3 Other
Projected Daily Flow: 36fl g.p.d, Permit Vali
Proposed Wastewater Y� e9'�: / �D � �
Proposed Repair. 1SGKi «Q � Go � v.
System Type � _�.
Permit Condition�� ��� 5'�'7 �'k +
Owner or Legal Representative Sign re: Date:
Authorized S#afe Agent: pate; �' " o� � O �
The issuance of this permit by the Heafth Department i no way guarantees the issuance of ofher pertnits. The permit holder is
responsible for checking with appropriate goveming bodies in meeting their requirements. This site is su6ject to revocation if
the site ptan, plat, or the intended use changes. The Improvement Permit shall not be affected by a change in ownership
of the site. This pernnit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatment and
Disposal Systems of the North Carolina Administrative Code.
/ �
Wastewater System Description: _/`f0 X-3 �n ✓�Jr�. Wastewater Flow: ,36n q,p.d. Type• �-
Faality Description: 3 gY• S f ��-�–! ��,�, {Vew� Repair ❑ Expansion ❑
Basement? 0 Yes No Basement Fbctures? a Yes o
Wastewater Svstem Requirements
Tankage: Septic Tank size 0 � gal, Pump Tank size ""— gal. Grease Trap size —"� gal.
Trenches: Total length /! a ft. Trench Width 3 ft. Total Area �� sq. it.
Max. Trench Depth: � in. Aggregate Depth:1� in. Soil Cover. (D in. Trench Separation �ft. on center
Permit Expiration Date: ^ a– �
Authorized State Agent Date: ��� ��
�Ses at4ched site plan and add�ndum pages for additional permit conditions. '�
��-----
The type of system permitted a does C! does not d'rffer from the type spec�ed on the application. t accept the
specifications of this permit
OwnedLegal Represerttative Signature: Date:
O�eration Permit
Type (in accordance with Tabfe Va) � �
tem has been installed in compliance with applicable �lorth Carolirta General StahrtBs, Laws and Rules for Sewage Treatrnent
�sal, and all conditio� of the Improvemerrt Pem�it and Construction Aufhorization. Issaance of this permit implies no
�e'tha�the�sy�siem ins�kled wi(1 function pro�serlyfor a�ry given period oftime.
s��� �a
State Agent ��/��� Z � � rDate
PCHD, rev. 03/07/01
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Tax Map #: I I � � . Parcei #: � � � T
Zoning: Township: �u►�n r'r�i ��'1
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Subdivision: . Section: Lot:
Ch �UCf"-s
Appiicant• � n J �
LocaUon• � � m u��� ��'
�peration Perm it
System Type (In Accordance With Tabie Va): �
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND J�LL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
State Agent
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