A40 109� It � � n Dat ' � I -� -6 d
�►maunt Psid• 3��
��3 �
��
. 3.�,2. I
�'
Person Cauntv Heaittt Deaartntent
Er�viroementai Healtl� Sedion
Tax n�ao #: f�'�� `�/t�
Par+cal �: �
IF THE INFORMATION IN THE APPUCA?10N FOR AN IMPROVEMEidT PERIIAIT 19 FALSiRED. CHANGED. OR THE SITE 1S
ALTERED. THEl�1 THE IMPROVBIAENT PEitMR AND AUTHORI7ATION TO CaNSTRUCT 3HALL BE�OME INVALID.
� a��d �71� I��Pedilro Ownerj- l�Po /iNA .�e �O�c�iD �1/
Home Phona ���I - �� Addree�
Buslr�s Pttarta: . .
2) Naitro and � of carrent owner: C�'t2�L�'nR- /�e��2a/✓ .
s) P�roperiy Dapiptlon:
Dinedlons to the pcot�
4)
�
�
��r
Proposed Use Strueturs Desctiption: answ� earh of the foUawin9 q�ce�on�
� a) ProPoaed �E�9 �
b) SHdc Bu�t Q Modutar Q Singte Wide Q Dauble Wtde Q
c) Nurnber of Bedreoma• . . c� Number of ccc�perria ar people to bs se�ved:
e) Basame�tt Yes Q No ye� # of b �mant �uex
fl Garbage Dtsposai: Yes q No �
gj Dimenalana ot Proposed : Wldtlx� �epdh: � .
Wa�sr SuQ�hl Type: new � ar exi�9 C�. Pub% 0. CamgumiiY o, S�9 a �
� � Are atry Wnells on a�oi�9 ptopeKy? Yea�e'No D lfy�. loc�On
� t�ease tndtc� o�ired syst�sm Type: (sya�ns can bs ralload in or+�er crYo� P��)
„�Car�v�ntlonal �Mo�ed Cornrenttonal _ �ve Innovative
.Dther isP�fill�
CLFARLY STAl� ALI. CORNE�tS AND l.WES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
P1.EA.SE ATTACN SURVEY Pl.AT OR S1TE PUW TO TH19 APPIICATION
I h�eby make applica8on. to the Person CeuMy Heaith Departrnent ior a site �or� for the on-a�e sewage dtsposai sysGem for
the above-deacxt�ed �+cperty. 1 agree tt�t the � ot this app�cation ara true and represer�t the ma�anuvn faa'�S to he
piaced an �a p�operiy. 1 understand if tha site is a�ered or the irrtended use changa�, the permit shail becmrta irnra�d. I un�nd
that as app6c� 1 am nesponaibie for id�yin9 ���9 P�'��hl Gnes. camers and meidng the site � fior the
personnel of erson County Heafth Departmeirt to conduct their evaivations. l �mderstand that I am respor�ai�e for not�ying the
Heafttt D ifi mY Pro ' acql wetlands as designatad bll ��Y �� ��� .
. � � • " �D .
-` . awner or al Represa�l++e . Dabe -
PC}i�. rev.10f1?J99
_ PLEA�
Tax Map #:
Zoning
APPUca
Locatla
PERSON COUNTY ENVIRONMENTAL MEALTH
v Pucel i
Tmunehln
Subdivislon: �O�O17�� C7�e/J 3Ktlon: Lot �
Improveme�t Permit.
�
New `� Repair Addition Type of Strudure� Water Supply Q�'�•'�
# of Occupants 6�'� #•of Bed�ooms -3 Other
Basement? Basement Fixbures?
Projected Daily Flow: 3�f� g,p.d. Pertnit Valid For.� Yea ❑ No �xpiration
P�opased Wastewater System Typ$;o �-o n uZn ��`o
Pump Required? Yes � CanUen��p
Proposed Repai�: �a-, n�,� �c �z P� �
Pertnit Canditions: � �
Owner or Legal Representative Si�
Authorized State Agen� �
Date:
Date: -
The issuance af this permit by the N�alth Department in no way guarantees the issuance of othe� permits. The permit
holder is responsible for chedcing with appropriate goveming bodies in mee�ng their requirements. This site is
subject to revocation if the site plan� plat, or the intended use changes. The Improv.ement Permit shall not be
affected by a change in ownership of the site. Thls peRnit is subject to compiiance with the provisions of the
Laws and Rules for Sewage Treatrnent and Disposal Systems of the North Carolina Administrative Code.
Type of Wastewater System Cfifl i
Faaliiy Type: � �,� � f ft�!►'e� �
Basemenl? 0 Yes �No
Wastewater Svstem Reauiremenb
Septic Tank Size: l�i� gallons
��A"+�% Wastewater Flow���a.p.d.
New� Repair DExpansian 0
Basement F'�ctures? 0 Yes 0 No
Pump Tank Size• 'vt� gallons
Totai Trench Length: �l�D feet Maximum Trench Depth: � inches Aggregate Depth:� in.
Maximum Soil Cover. _ ��' inche;
J Other. in.S
Trench Separation: � Feet on Center
Pertnit Expiration Date: � ' 1 1 ��
Authorized State Agent: � � Date:--t,�-�-=� �
The type of system pertnitted does 0 does n t differ from pe specifled on the application.
the speciBcations of this permit,
�
Ovmer/Legal Representative Signature: � a{�• �'�� � �/
. PCHD, rev
I accept
11/18/99
Application #:
Tax Map #:
Parcei #: �
Person County Health Departrnent
Environmental Health Section
SITE SKETCH _ Go��
�o��� �'�eloc� Co(� ►��
Appiicant's Name SubdivisioNSectio ot#
S .� � / a� �
Auth ized State Agent Date
System components represent approxi»urte contours only. The contractor must flag the system
to be�innin� the installatinn to insure that proper �rade is maintatner�
i�
I��.��`
Scale:
/
� � Q�a;n��
5 h�..�. rta,',, fa�
�s ' .��-6���
PCHD� rev.10/12/99
Person County Health Department
� �Environmental Health Section lo (�
Tax Map #• � � Parcel #• �
Zoning: � Township: '��� R � i) �
Subdivision: �� � 11 � �S Section: Lot: �
Applicant: �ix i'Dl � �. ��'�'��"' � on
Location• (ni 7
Operation Permit
System Type (in Accordance With Table Va): —
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZATION. _
� /`��
�
Authoriz d State Agent
.3 � a �o
(
Date
Tax Map #: Parcel #:
PCHD, rev. 10/12/99
Person County Health Department -
Environmental Health Section �
Zonfng: Township: �l� �`!��-P�
Subdivision: __(.d1L�'1`'� � Section: L-ak �
Appllcant: ,G 1' D l r/�� �,IDG� �rc�S/�
Locat%n: �7 � � �� 7'� � �
Operation Permit
1. LOCAl70N AND SEPARATTON DISTANCES �-�
A) System meets .1850 setback requirements
B) Distance from system to any weils f�s �
C) Distance from septic tank to foundation �� �
D) Distance from system to property lines l0
2. SEPTIC TANK �
A) Vsually inspect the exterior walis and top of the tank �
B) Visually inspect the interior waits, baffie, tee, fiiter, riser, lids, air vent,
bottom, and water tight ouUet -�-� -
C) Date of tank manufacture �
D) Tank seriai number 5T� �
E) Liquid capacity of tank i.o oa gallons
3. SUPPLY UNE TO TRENCHES
A) Grade (1/8 inch per foot minimum)
B) Material supply line is constructed from
C) Diameter
D) Length
E) Distance from tank to drair�fieldldistribution device _
4. DISTRIBUT'ION DEViCE(S)
� i1 S
. A) Type -
) Is Device water iight _
� C) Distance from the distribution device(s) to the trenches
D) is the device on a levei foundation
E) �oes the device pertorm according to its design specifications
5.
� Record the iniet and outlet elevations
NITRIFiCATION FIF� n
A) Trench depth a inches
B) Trench width � inches �( O� �
C) Distanca between trencties
D} Number of trenches � .. l
� Length(s) of trenches
'� Aggregate depth � inches � �
G) Aggregate material and size
H) Record septic tank outlet elevafion 7's� "
I) Trench grade 5� o��a ��� L 1/4" per 10')
. J) Step downs �
a Minimum of 2' of undisturbed earth �
�
�
b. Proper rise aver step down �
c. Soiid pipe used �_5� �(�� '�
d. Elevations of step downs Record vations and show on as buiit)
See "as built" �lan on attached sheet.
PCHD, rev. 10J12l99
�
.�
PERSON C�UNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL S1TE LAYOUT
T� �p � A�V Paresi # r v�
��� ,
Zoning
Township — �
� .
AppUcanC �O' I /�-�+-- �� .
_ n �
�
Tvpe of Water Supptv:
Reauirements•
Sectlon: � �
Well �ermit �
Individual Community Public
Site Approved by ✓�� •%� � D J
Grouting Approved by � S 3- l�• a�
Weil Log .
Weil Tag f �
Air Vent
Hose Bib �
Concrete Slab �
Well Driiler:
Well Approved By: � - �
.*
Date: �/��/�
**See Attached Site Sketch**
Wells must be 10 feet from �property lines.
Weils must be 100 feet from septic systems.
Welis must be at least 25 feet from any b�ding foundation.
Other conditions:
�;.
�'
PCND, rev. 11/29/99
Barnatse W�11 Drillinp Inc
d
Date: o .
Owner. '
L,acation/Directians:
336 598 9275 GJ5/24/Qll 08:S1A P.001
P�RSON COUNTY ENVYIt02tMEHTAL H�ALTH
WELL LOG
SR#
Svbdivision �Name: _ _______. Lot #
Dri�ling Conttactor: �� 1�� � wQ�'. � '^�
WEL�, CONSTRUCTTON��
Distance from Nearest Properry Linc 1 v D'utance from Source of
Pollution t G o „
Total.Dep.th:�,.L�p_C�. F� Yi�ld:�`',�_ GPM Stacic Water Level�Ft.
Water Bearing Zones: Depth �_�t...l1..4 � ^F�.�'�,�_��_ __ __Ft.
Casing: l�epth: From C� -Lo,,,��_..�t. Diarnecer:,,r�._,�nchcs
TYPE: Steel • Galvanized Sce�l -�
If Steel, does owner approve: X�s______� No_____.,__.
� � Weight�:_____._ Thickness:,,� '�' Hei�hr Above Gzound:__L__`�i .._ Inches
Drive Shoe: Yes �' No .
Were I'roblems �ncaunt�red in Sctting the Casing? Yes_____ No__�_,_
It "yes" gi� c Ycason:
Grout� Type: Neat SandlCem�nt /' �oricrete
A�uw�ar Space Width Tnches . �
Water in Annular Space: Yes�_,,, No
_ .. Mathod: Pumped : �Fiessure��Poured,!� � '
I�epch: From O :,o .,�-O _---��.
Materials Uscd: No. Bags Panland Cement Vi�eigj�t bf .1 bag�lbs.
T,f rnixture (sand, gravel; cutunas) - Ra[io:�. co
IU plates: Xes � � No � '
� 4 x 4 slab Xes �_ __ No .
I HER�$X CERTIFY THATTH� AB4VE INFORM�TTON IS C4RRECT�AND TI�AT
THIS W�LL WAS C4NSTRUCr'ED Il�J ACCORnANCE WIiH REGULATIONS S�T
F4RTH By•THE PERSO�r C���aTY HEALTH DEPARTMEN7'.
� naturc of Concraccor p�«' �.
'�
�
�• LotS'�: �• �2 �u�ti�,+ision: j �' 1C.. � jot�
s} �_ oneL s�ie�#3i�o:.. —�----- / �n .SD I S r�.ltx
R ,�}rSrnen .snril�LP t�IYAGjYi�T1S �O �� ���I'� �'� � i s� /
Q}R.'S �! il� !l0es turs sstc w.,ss.�.+�.. d �-----------
II yes II r�o Does tize sit� �oniain any �g ���T ��3ns�
II yes II no Is 2IIy rraste��ater gn�g to be generat�d o� tne �ite �ther than d�me�tic s��`'
Q y� II no is-thesite snbjectta appravai bY a�y ut�rpublic agenc}r�
p yes II uo Are t�ere anY easemeuts o�rr't�rt� r�vays an �c�e�ta�ianj
('ff ��s' i� checics�, pleas Pro �A T�
�i� ��rEle'2s�3�E�? 1�5E �� ��. t3s r�� t ° .
I��Fs:esII�I —
t7 Net�t Single Fami�Y �5�d�ic.� i4f�.�imum nua�ber a� brdraoms: _
❑ Expansion a��istin� SS's�m Iiaxp�ion: Curraui uumber ofh$drocnns: _.–.
Q�.epa.ir w iv�aifunc�ioni�g 5ys�m Wili ther� be a�asemer�? C1 yes Q no t�'z�h pium�tn�
a� n�
QI}io� �iden�iai ' �`ot2i Squar� foota�e of $uilct�� �
'��pe o��s: i►11�imum number aisea��: - �
�tif�.-'rmum nuraber cFemploYe� _ 3
Y�eII Li Cosr.m�sniij' i�Ie1I II Prsbtic 'Watar Q�pr�� Q na
5) "vrlaEe� �e���3r II New,�ell Ll Exis�n�V IIS: Sj}TiA°�S OT �h�St1Aa L�'�tetline5 rn1 this gToperly`I' L� Y�
AT2 FIIEI'� 2IIy B�s � - " � ..
t
.� ;�
(}} a= �.t4...i r��. � C g �� s� �. CL'ic`�F°�� � C�:r'�iE3`���g ���€'r }�'��''r� fy.�i�i€'s.�` {'sE� �� d ..r���° � � _ _
� t PrI�}�
L7 Can�lentianal � Accepted E[ %mo�attt�e Q����� Q Ot�er �
%�e c�d co�ec� :t ctlsa �ders�� �� �Q�°��°�'ided is
I c�ti,�"y �&at the �orma�n�t'ovided above is comp ��rwuls sIzall b� i�va?id. :
irracc�are, ar' if � s�te i.� �%�Y aite�d, or the mtersded �e ch��, �ttl pe�tni�s
/% � w• / 1 _w 1 /�'�D �l't//�
Y 5`�pgartin�dac�maentationr�q�a�ed.
y��{/��f/�M /��.jpy�{y �``{
s�^�{"IS�j1Sjf1iY{fi��f��R"Y��L'ii�E7Sl����JiP�L`�.:.�����+f3YVYY���"{5 `, �
� � Q��! TGI�wi�.swY� n'�'�
.A. r��p� `��reg�r�iiong � � a�r��a� �g ��������? o ��a�� � :�,
- — - ..T.t..:,r�� r��s cn� ��nn�
���.sf ���.���
�--�- � � ����
1E�ra�n�-���nm�ra��.Il IE3L� a fl �lEn.
WELL PEA ✓
(New_ Repair_)
Tax Map: o Parcel: �_
Subdivision: -
Applicant's Name: �i r � �
Mailing Address:
�
v
Phone Numbers:
Location of Property:
� � , � _ .
Lot: �_
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulations governing construction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not guarantee a potable water supp'y
Other Conditions/Comments:
Permit issued
�iew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Additio�al Comments:
Date Sample Collected:
EHS:
Persan County Environmenta� Health
325 S. Morgan St.,Suite C
Rnrhnrn NC. �7573
Date: Z-![-llv
Certificate of Completion � � ��W � Z�,,�Q,
ti�� �,
iner:
EHS/Date
Depth: 77 r
Grout: Z-IY-! �� .
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
,t���l,a