A35 177` � � �,�1
,��Diicaiion Date:
Amount Paid: �
Recsiot �t: ���
oa
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�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 �
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. 9�bdivislon• � �_��: .. .8eatton: l.o�
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�on: � �� (��1� % �-
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. , System '�ype (in Aa:ordarice Wiih Table Va): ��
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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 �
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Authorized State Agent Date
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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:
� �, ,`�� .��,
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" PCHD, rev. 11/29/99
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�" 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