A40 129Iication Date: �' � � �bd
�mount Paid: �
Receiat #: 2 I 4�
Tax Map #• � �O
Parcel #: f .� �
Person CountY Heaith Department
Envi�onmental Health Section
. APPLICATION FOR SERVICES .
IF THE INFORMATION IN THE APPI.ICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED. CHANGEO.OR THE SITE IS
ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID.
1) Permit requested by: (Ownerlag ��prospective owner): ri �.,-rr s' �\��J ,� c S�.-��y �e
Home Phone: �2.5� — -0a2 Address: au� d-S ��h �
Business Phone: ' -DS�`� ��YKc��e�'�'a�n .�c, a-?s'3G
2) Name and addcess of current owner. ��� �Sc.,�� �ff
3) Property Description: lot size: � Township: �`�%��ri�c �
Directions to the property (Induding/�pa/d names and numbers):
�(�,lG�v! r T I � A �YS �'f � �
4) Proposed Use �d Structure Description: answer eact� of the fallowing questions:
a) Proposed 0; Existing ❑
b) Stick Built �, Modular �, Sin le Wide �, Dauble Wide 0� �
c) Number of Bedrooms: � � Number of occupants or people to be sesved: ��
e) Basement: Yes �, No C� If yes, # of basement fixtures:
� Garbage Disposal: Yes �, No �
g) Oimensions of Proposed SUucture: Width: �, Depth: �
� Water Suppiy Type: Private,9 (new�-or existing 0), Public q Cammunity 0, Spring �
Are any wells on adjoining property? Yes� No O If yes, location
6) Please Indicate Desired System Type: (systems can be ranked in order of your prefe�ence)
i� Conventional Modified ConventIonal _ Altemative Innovative
Other (specify):
-% CIEARLY STAKE ALL CORNERS ANO LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SRE PLAN TO THIS APPLICATiON
I hereby make application to the Person County Health Department for a site evaluation for the o�-site sewage disposal system foc
the above-described property. I agree that the contents of this appGcation are ttue and represent the maximum faa�ities to be
placed on the property. 1 understand if the site is altered or the intended use changes, the pertnit shall become invalid. I understand
that as applicant, I am responsible for identifying and maricing property lines, comers and making the site accessible for the
pecsonnei of the Person County Heafth Department to condud thei� evaluatio�s. I understand that I am responsible for notifying the
Health Department if my properiy coniains any weUands as desigrtated by the Artny Co�ps of Engineers.
Owner or al Representative .
-Do
Date
PERSON COUNTY ENVIRONMENTAL HEALTH
•' `, • ` PLEaSE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map S: 1/�� Parcel # �/
Ioning
ApPlicant: �C��ln """ r�'"�"� ' .
Township Fla-� R� +��r
LocaUon•
i
Subdivislon: �OIOn ICI) ��tsSectfon: Lot:�
ype of Water SupplY:
Rectuirements•
Well Permit
�/ Individual Community Public
Site Approved by '�'' �
Grouting Approved by 3n► i-+ ���-��
Well Log ��-�v 3"' �f
Well Tag ✓7-als-oo -S •
Air Vent ✓ • aJ -�� �-S �
Hose Bib -� -�� � 'S�
Concrete Slab�-7� S•a� �'
Weli Driller: �' �- ��� �' � l� "`� .
Well Approved By:
Date: � ' �� � � �
**See Attached Site Sketch**
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions: lict (,,��,11 5'Q' FroM homc LJ�- f I c�ri I Ic� S�•ou(d
c.�t ENS on 5itc- Pr�vr-tn 1`n5�1(a��on .
PCHD, rev. 11/29/99
f
t 7
PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAYOUT
iaxMap#: ��v Parcel# ���
Zoning Townshfp ��� � 1 VC.r
Applicant: ��r,� ��re�-E
Locatlon: I cJ 7� L�-J W�� f a� E,,�j��C'�CS Lot an �
Subdivision: ��iDl1 fal ��wS Section: Lot: ��
Improvement Permit
A buildinq permit cannot be issued with onlv an Improvement Pe_rmit
New V Repair _ Addition _ Type of Structure�� Water Supply Qr'� �%a� ���
# of Occupants�X # of Bedrooms � Other •
Basement? lf� Q_ Basement Fixtures.�1��
Projected Daily Flow: �Df.� g.p.d. Permit Valid For: U�Five Years ❑ No Expiration
Proposed Wastewater System yype: � CAlI U � Il'EI a/1Ct ���T"CcV ��
Pump Required? Yes �� No
� �
PermitConditions:�t�T S;St�c.m �� a�F�r c ��cs,j l���o�, �r'ain, S'F�m I�D^'i�i
Ib0' From We,l`. -'�il'�c.�£ �F{Sar1 ��'tt For 10.yoc,�� A�i�r t-a i�s�l�0.�r�n-�`'
Owner or Legal
Authorized State Agent:
Date:
Date: � l i'�v
The issuance of this permit by the Healih Department in no way guarantees the issuance of other permits. The permit
holder is responsible for checking with appropriate goveming bodies in mee6ng their requirements. This site is
subject to revocation if the sibe plan, plat, or the intended use changes. The Improvement Permit shall not be
affected by a change in ownership of the site. This permit is subJect to compliance with the provisions of the
Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code.
Authorization To Construct Wastewater Svstem (Reauired for Buildina Permitl
Type of Wastewater System.�{ CAi11�G�i W�1 Wastewater Flow: �Oi� g.p.d.
Facility Type: Dbl �G hOn'1G
Basement? O Yes o
Wastewater Svstem Reauirements
New �f Repai� DExpansion ❑
Basement Fixtures? Cl Yes l�lo
Septic Tank Size: ��� � gallons Pump Tank Size: N/�A 9allons
Total Trench Length: 1� feet Maximum Trench Depth: � inches Aggregate Depth:� in.
Maximum Soil Cover: � inches Trench Separation: 1 Feet on Center
Other: K� (��-II �00' From 5e�ti`c ���� (in4f On ('��u�
Permit Expiration Date: � � � �O�
Authorized State Agent: , Date:�.!' r �-0�
The type of system pe itted 0 does Q does not differ from the type specified on the application. I accept
the specifications of this permit.
Owner/Legal Representative Signature:
Date:
PCHD, rev/ 10/12/99
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Person County Health Dspartment
. ' - ' � � Environmental Health Section
" Tax Map #: Parcel.#• ��
Zoning: Townshlp: ' ��j� �, tl �Pi�.
� on• G��D Sectton: Lot: f 9�
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O eration Perm it
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 CONSTRUGTION
AUTH�RIZATION. .
�. ,.. -- ��� ��' , �.�'! � .---� .
State Agent
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Tax Map #:
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Date
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PCHD, rev. 10/12/99
Person Counfy Health Department
� Environmental Heaith Section /�
Zoning: Township: ����`` ��P�
Subdivision: Section• Lot: % ��
Appiicant: ��,�n �
�ocation• L C L.o� on �
Operation Permit
1. LOCATION AND SEPARATION DISTANCES �
A) System meets .1950 setback requirements lI� ��rr �/�
B) Distance from system to any weils Il��1Tr G�e� � �
C) Distance from septic tank to foundation ��°n S�� �
D) Distance from system to praperty lines !o
2. SEPTIC TANK �
A) Visually inspect the exterior walis and top of the tank �
B) Visuaily inspect the interior walis, baffie, tee, filter, riser lids, air vent,
bottom, and water tight outlet �
C) Date of tank manufacture DUa
D) Tank serial number
E) Liquid capaciiy of tank Ia�D gallons
3. SUPPLY LINE TO TRENCHES
A) Grade d 1/8 inch per foot minimum) �� �U�
B) Material supply line i constructed from
C) Diameter �
D) Length �O
E) Distance from tank to drainfield/distribution device ��
4. DISTRIBUTION DEVICE(S)
A) Type �
� B) Is Device water tight _
`(�� C) Distance from the distribution device(s) to the trenches
j � D) Is the device on a level foundation
E) Does the device pertorm according to its design specifications
� Record the inlet and outlet elevations
5. NITRIFICATION FIELD �
A) Trench depth c�- inches
B) Trench width inches ��� C�
C) Distance between trenches
D) Number of trenches
E) Length(s) of trenches o�R ����
F) Aggregate depth �_ inches � s�
G) Aggregate material and size
H) Record septic tank outlet elevation �'/�'!
I) Trench grade �-ep e1 ro� v� � M� L 1/4" per 10')
. J) Step downs
a. Minimum of 2' of undisturbed earth �
b. Proper rise over ste _dQwn _
c. Solid pipe used ��-U �
d. Elevations of step owns .5�-dR'(Rec..�rd elevations and show on as built)
See "as built" plan on attached sheet.
PCHD, rev. 10/12l99
�
Nonn Carolina - Department ot �n�fronment and Natural Rosn��rces Ul�is�on o! Water Oua�iry • Groundwater Sectlon
t�36 Maii Servica Center • Ralelgh, N.C. 27699•1636-Phon� (91`1) 733•3221
WELL. CONSTRUCTION RECQRD w�.�� �:OP�7F�ACTOR: _ � G�� (t ,,�nxt��_��
1"JI:�L (;ONYRAC70R CEFiTIFICAiI(�N tt:�„,fQ��„,M_.. --
�"i't�TE WCLL CONSI'AUCTION P�RMI'T�: _,� —..._
��.-.e..,�..�..y�. ----
m�.�:,._�.,r.,:.,�.. ,�,l,.W..,,.a...� _. .
��,.. . --- -��-
�, LYELL USE (Check Applicabie ffox): Residenli8l � ��iunl�ipnl � Industtiat [� Agrlcultural �� PrlonitorinQ �
Recoyery Q Heat Pump Water Injectlon �} OU�er (� I[ Othar, List Use: � -
2. WELL �OCATI N: ( ow sketch of the locatlon boio�.v)
Nearast Town: c` _.,.--- Counry: ����' � ---�-�-�
� :!� � o� � s �!r � �....--- . ___._ --� - _ �: r H _ �
(Road Nsrt1e and NuntDer�, Co m�n(ry, or Subdivlsion Ana Lot P;n.) DRILLiNG LOG
3. OWNCR �� _., _-�--.. --_ From 'fo formstion Descnp �an
Addt05& �'{ 2 5G , �''�'ty I � l U``._„,__ "- � � �
�"`"^rStree or o a o.
.,��,, �� ..ur "��Oj , p - ,� _!'.?��.�. -
City or ow� Stata 2ip Code _
a. DA�'EOpILLEb ���3��" - o (� �._--�
5. iOTAL DEPTH � ,,,,,�._...,,__ - -
6. CU1"l"INGS COLLECl"�p YES �] NO _�✓ -""
7. DO�S W�l.� R�PIAC� EXI�TING WEL�? YCS ❑ r�0[� -�°"`�'—`"""""-
8. S7ATlC WATER L[VEL 8elow Top of Casing' .� �?,,,,,,_ ��� ��- -•—' '�
' (Usa'�' u ADova Top o{ CasinG) _ �.........—.—.....-�. - - ---
9. TOP OF CASING 1S_..,� FT. ASovo L�nd Suctzco� �,�N____,_,_,�.
�'1'op ot caatng terminaled nuor hataw lahd 6uNaca reqvlrea � v. rl<,r,ca In sccor �^ �^_ � �,_____^�
dencow1ui16ANCAC2 i�l1B � �,d_
10. Yl�L4 (gpm): `� METHOD OF TEST ,��`�-.' ' - --��°M"—�"�"' ��
11. WATER �ONES (depih):._�---��U �--� .-,--- ' ^ __�� f� �
'{"'(�' Mtouril _e�'�.____ It addiUonal epaca ig naed�d uso b�ck of lorm
12. CNLOFiIPlA'�ION: Typa _�..--�--�- �„___--�,�:_�
13. CASIPIG: LOCATION SI<C'f H
WaU TT��ctcncss
'-t Depth �a ter or W � �vf't. i�n'n�tfena_i (Show direcli0n 8nd dislanCO from at IQaSt ttvo Statc
�fOm � J - TO -� �t• ��� =��� -�i� rt( Roads, or olher rnap reler0nca points)
F�om To. -- Fi. --._ . _
Krom...�--70.�---- Ft.. - .__. _ _ .�.
14. GROU7:
Depth � rv�s�y,od
Fram ��
To �.-.. Ft. -- . �'ut� —
From �'o Ft. --- •�--- - -
15. SCf���N:
Depttt Diameter Slot Sizo Mai�rial
Fram .--.�To Ft..._....� in. �iri..�.._.. -.
���
�
P�R�C 5� ��
�,�jcSY�
7o Ft. in. ., 1r�. . ' �
�rom --`-'� --
From ._.,^� To �_ Ft. in. in. ._._.�. � ,
16. SAND/GRAVEL PACK: C�o '�`� �"�
papth Stio M�torial
Frem .^r__-_ To Ft. _ - .�-.-.--__-- _
From To� Ft. Q- ____� ._��._� .�.�� _
17. A�MARKS: �....�_.i�_t} � __-
I DO HEREBY CER7�FY i'HATTH�3 WELI. WAS CONS�� fiUC�co W�CCoa�{WCE WiTH �sn NCAC 2C, wE�L
CONSTRUCTfON S7ANDARDS, AND 7HAT A COPY 0�' Ylil;,', RECURD HAS EE PROVIOED TO 7HE WELL OWNEA
���
�� ��.�,. .,�_ ._-_ �-�-
FOfi OFFIC� USE ONLY —�--�--�-----�� UAr�
Quad No: SIGFI.�YU1;!c Ot' PERSON CONSTRUCTIN� TNE WE�.l.
SNbmlt o�0�nc7 l0 4: irtsto�� o� �'latur Ouality. Ground�va�u� Sea'on within 3a days GY!•1 iIE V. �?l�9
Sedal No.
T0'd Tt�6T 8ZS 6T6 `�hII`_lNI-1-lILIQ1"13M3�H l�iti LZ� Z� f1H1. OFJ- 6Z-Nflf