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A35 177` � � �,�1 ,��Diicaiion Date: Amount Paid: � Recsiot �t: ��� oa � ���� -ol � �-� � � �prson Caunfir Health De�artrnent -:�r�vironr��nta1 Heafth Section Ta� IU1a �: Parc�l �: 7 ' �`:: APPUCATION FOR SERVICES � IF THE 1NFORMATiON IN THE APPLICATION FOR AN IMPROVEiNENT PERMIT iS FALSiF1ED, C4iANGED. OR THE SiTE IS ALTERED THEA1 THE IMPROVEMENT PERMIT AND AUTHOR(ZATION TO CONSTRUCT SHALL BECOIIAE iNVALID. 1) Permit requested by: (Owner/agentJprospective ownerj: l=2r=� ��� D A H� raTo �� • Home Phone: Ao4 - 793 -GQ4a Address: 25o NotZ�-a.�r��c,�a-c T3�.vU• Business Phane: .PFTiiP�'r� �A�.1Y��L►�.. VA. 24540 2) Name and address of curcent owner. �2t_ ��, Ao �� �1i �aro N. 2'�-� �1c� cz-L u. Mcti �T 'I�.�! �• "t�A���vt��r . �/A, zd �40 3o q� � 3) Property Description: �otsize: �`fownst�p: L�cc�oS�A�G Directions to the property (Including road names and numbers): _� s+� �33� �= Roao 4) Proposed Use and Structure Description: answer eact� of the following questions: a) Proposed C�7!�idsting ❑ b) Sadc Built C�,'1Godular �, Single Wde �, Double Wide ❑ c) Number of Bedrooms:. ,�_ � d) Number of occupar�ts or people to be served: _� e). Basemenh . Yes �. Na t�if yes. # qf basemerrt fixtures: . . . . . . . . . .. -� = •-. � � Gart�aae. Disp _c^�1: YPs �!��:. �-.: . . . _. -- ,..: .. _ ..., ,: . .: � ,. .. . : . . ,� . . - . . - ._. ...__. . __ . .. g) Dimensions of Proposed Sttudure: Wdth: � Depth: *' �' � Water Supply Type: Private l9'�new �existing �), Public �, Communityg, Spring � . � Are any wells on adjoining propettYT Yes � No �'(f yes, location fi) Please indicate Desired System Type: (systems can be ranked in order of your preference) ✓onventional _Modifled Comerrtional _ Alternative. _Innovative dther (spedfy): CLE.4RLY STAKE ALL CORNERS APID UNES OF TOiE PROPERTY. STAKE TNE CORNERS OF ALL PROPOSED STRUCTURES. PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for the above-descxibed property. i agres that the contents of this application are true and represent� the ma�timum faafities to be placed on the property. I understand if the site is altered or the irrtended use cfianges, the permit shall become invaiid. I understand that as appiicartt, i am responsibie for identifying and marking property lines, comers and making the siie acr.�ssible for the personnei of the Person Courtty Health Department to condud their evaluations. I understand that I am responsible for notifying the Health Departrnerrt ii my property contains any wetlands as designated by the Army Corps of Enginesrs. ����. � ���� � !o-ZI-OI - Owner or Legal Representative Qate PCt-iD, re�►. �a�zrss r� i...�.a�.� ��:� �� ;,� ; ,�d T� ",fbg � .7S par�! ;�p� f r.�� /W'G��� M New , Additiort _ # af Occuparrts�QX' � Projeded Daily Flow: _ Proposed.Wastewater Proposed Repair: � Pertnit �wner or Legal Authorized State Agent ���v�� ���h�� ��.���'��ME��'�;�. �?�+�.�� Trn�Q� PlAt 2� 0-y,, rrn��rrar��e�raer� ���r� ' �_:: ,-;�� �5�� 3 �R 1`� ,�, N iI� M;. W�-�p�,, �'e�� sedrooms 3 Other system Type��, _ g,p.��� Permit Vaiid �or. Ne Years ❑. No Expiration �1= The issuance of tttis permit by the Health DepartmeM in no way guarantees #he issuanca af other peanits. The permit hokier is rssponsibte for ct�ecking vv�h appropriate goveming bodies in meeting their requirements. This s�e is sub�ect to revccation if the siie ptan, plat, ar the inbended use �hanges. Tl�e.Improveme�t Permit shall not be a�ed by a c�ange in ownership of the sibe. This permii is subject to camptiancs with the provisions of the Laws and Ru(es fior Sewage �rratrne�rt and aisposat Sys�ems of tfie �lorth Carelina Administrative Code. Wastewater System Qescription: C�Vt `�' _ Wastewater Flow: _ Faa7iiy Qescxiptio�• 7d�1C "1 ���� ' New� Basemerrt? C3 Y�'s "�-Plo � Basemerrt F�chuss? 0 Yes�1No Wasbewabe� S�sfiem Reauir+emerrt� Type: ` l� Repair � Expansion ❑ Tankage: Septic Tanic size coc� gal. Pump Tank size gal. Grease Trap size gal irenches: Total length �� O ft. Tranch �dth �_ti. Totai Area `� � sq. ft. Max. Tcenrh Depth: r �% _ in. A99�Jate Depth: t Z in. So� Cover: � in. Trench Separattort �ft. on cerrter Permit Expiration Date: � Z� Z-`� . Autho�¢ad State Agers� �= � � �� � � 'See attacl�ed sibe plan and addenc6um pages for add�tionai persni! can�tioss. '�he type cf system permiited D does C� does ifie type sp� on the aQpGcation. q acr.�pt ifie specifications � this� perniit. . Owrteril_egaCRepra:sen�ive Sigr�ture: D�: � C9� Aie1�30n �eflllit S�stem Type �n acxordance writh Table Va) iisis systiem lras been ir�talled in comp� wifh appliCa6ta dloNh Carolfia C,eneral S�s, taws and Ruies for Sewra4e Treahne�st and Disposal� a�d al{ cwdilions of the Improve�n�t Permit and Cams�t�tion �r�a6on iswafu� ai ihis pemaii im�l'�s no gtiac�rtee t�tihe sysne�n i�i�d wii! f�at g�oPB�Y ��Y 9� P� ��- Autharized State Agertt. . 13ate � - �cH�, �v. a�ra7�o� � "� � • P. 286 �� �� 1S � �,h�y / �� _'_'- - - — 5�.� • . / / / ,�o 2e go, l / E• IIIfJTpN 49�, ��NTROL , � � 3� ��IIP,r���� N � - - _ _ �xIS�NC� .9�� � COl�NER � ' � / ��AApR� . ?o q�c� 1 F l � / / � � � ` • �1'I�llq� • A FSS F . ��sso. � � ' � �� �� F( o� S68 qSF,�� S o os, �/ � / ,�. , qTr NT ?, 29 / / � f� 'S 6� � . �NJ \ � ° . � � ��y'����� �� , �` o�F / IF � � � � � � ��� o i � NF � � J •: �o � � � ,�o' . � n � � i � � ° -� ; � ' � � 1 �� � �� � o �a ��� ��� ,� �� � � ��� �L � . , , . � � � � .��,�° _ � ,/ ,��� ,``� �.��"'-w`'� . � � � �,� , � I S � ,� � - v Q���( / �i �O� �'� / /1�� , , _ �.. �Q� v� �,y�o � �Q � � �°i.'`�'ti � i � /11 J _ ' .,L•� s �"'s� %�i p�l / G,,y�y / �.i �/ �, �( r�S � �', . =1 ' ,' � � � � t � o � . � � �j D �'M WP� c� j � �� r � / / � ��— ��s �6 . , / � � � ��� o. 6 � X Q� , /� l� � � Uh . O 9.,� 9� � � � � / ' � d - � � , � �. � , � , � �, ��� .� �� j� o ��., �'�^� �j Ns � I� s� � � � �e(�. � , �r�, � � , NS � �,.�,,, s-r � j S32'3e�o8�� � y -A�A �• Fll ' S o �/ 6p� 98 � W' 0 N�`l 'D�RI C NTOIy �p� NS/ �- S3p •p2 , lJl�l�'�"`� "'_ 1�� .B. 311�Hp,H174 N /� � i 49, 14nW � ��U�'�- � 89 � � � � / / � v /� , / is� ; , � , �,� S s`� � � . 1tiS �� � y �,� / �� �� , �o � � « � r �e��� 1 =1�� SR 1335 �o� R�w ��,,, �++. � ���� C�% 3� o M��.E. 10 SCZ 1�'a3-I / . . , • .`1� i �,� �.��.1l��1.�J�� " • . .. • �' - '. �i•�/ t��� • . . ]���a�oaa �*�* �aa�m.lE 7F$�c�71�7L�i. . - -- .-...: 7,� N���, � �j : .. ' Parc�l �: � � � � ZoNng: Townshi�: • . . 9�bdivislon• � �_��: .. .8eatton: l.o� A�pUca� � �' �on: � �� (��1� % �- ; �p�ration. Perr�i�t � . , System '�ype (in Aa:ordarice Wiih Table Va): �� . , . . T�IIS SYSTEM HA� BEEi�I IN3TALLED IAi COAAPLIANCE VYITH APPLICAHLE N�RTH ��1ROUNS GENERAL ST�ITUTES, RULES FOR SEWAGE TRE�►TAIENT AND D18POS�►L, AArHiD �1LL COND1710NS �F THE IMPROVF.iIAE�IT PERAAff A�VVD CON3'�"RUCTION e�irr�o�n � . C� � � ��3�°� � Authorized State Agent Date .. ._ _... _ - . � �. � � �. � `.-fi-�"�'g � . -C�s� � `� . . .� `�� r�; . - � . - � ���: • . � �: . Y..:s . 6'► l J �' - ���� ... . . . �� �� , S . � � , { �� � 2� . �-- � � /�, � , • M r J . , G' �► � -. : � , � �� r�—�- . . ' C�,,��r �-�,, �. -�� . ..;. � ����-� .. � � fi�����- ��� ��� U . c..b c�e,��,e�Q a�vu� �fi S��f ��y, 9 0 0 _. . _ _.__ _ _ _ _._ _ _. _ _ .. .. ._. _._ _.. _ _ _ _. _. _ _ _ .. . __ . _ _ __ _ _ . PERSON COUPITY ENVIRONMENTAL HEALTH � PLEASE SEE ATTACHED PLAN FOR WELL StTE LAYOUT Tax YaP �1: � � � � � � � � . . , TwMnship ZoNng_..--- . Appilcan� � � f l� � 1�1� 2�ati rN+2 .-. . _�nv, �N ��LiMA� b Subdivbbn: 8acdon: �'O� Welf Permit ' Tyae of Water Suaptv: �dividual _Community Public Reauirements• Site Approved by Grouting Approved by �''SS �-a��" . � � Well Log � Weil Tag � Air Vent - Hose Bib - Concrete Slab Weil Driller: Well Approved By: � Dafie: **See Attached S'�te Sketch** Wells must be 10 feet from property lines. Vyells must be 100 feet from septic systems. Wells must be �at least 25 feet from any building foundation. Other conditions: � �, ,`�� .��, �r� �� une�� � T� � �� � �� . " PCHD, rev. 11/29/99 0 ����� �� ���� �� - �—� ������ �" aa�a.�-o�aaan�gn�.�.Jl ���.jj�.� Owner: Location: Subdivision: Driller ID # _ � Com��ny Name : , > D�t�e Drilled . Well Log Lot # Tax Map � � s parcel # �r� Well Construction Distance From nearest Property Line (Minimum 10 feet) /� Distance from Sepric System (Minimum 60 feet) m� Tota1 Depth: �$ yield: � GPM tatic Water Level: ��2- $ Water Bearing Zones: Depth �/� $ ft ft ft Casing: Depth: From 6 to ft. Diameter: � in Type: Galvanized Steel � Weight: �_ �ckness: 1 Fr f� Height above Ground: � Drive Shoe: ✓Yes No A,ny problems encountered while setting casing? Yes �..�to If "yes" give reason: Grout: Neat: Sand/Cement �/� Concrete GraveUCement Annular Space Width � inches Water in Annular Space Yes �--3Vo Method of Grout: Pumped Pressure �oured Depth � to � Ft. Materials Used: No. Bags Portland cement Weight of 1 Bag c' Pounds If mixture (sand,�'avel, cuttings) - Ratio o�_ ID plates: \�es No 4 x 4 sl�c�es No DI-illiIIg Log i.nc�tinn il�- �.x,�.,.� 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. Signature of Contractor ID# v 3 I)ate '� � a 7 Q v PCHD rev O1/16/02