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A40 131
b4�lyllbb7 16:39 3365977808 PERSON COUNTY p•l�/IRp PAGE 01 ,;:-. , ,�,, � • . t Y � -• �r1�•� �. : � + I 't►- � . •• �Z� • � O � 3����,6� 1,J O p��ei �: 13 � �-,_�� ...r ��IE�� ��' ���.,�...,�.�,� ��'�'�`�" ��..o.a�.. ��►.•: -,��. 'I) 2� Permit requested by: {Own � , ���-- Hame Phone• • q_s �p"D'�Ps��lva Qwn�r)• �. l d-. vw ( 1 Business Phoste: �'9� = �o Z ���' ?o � " r ��'^ � '2 ? 7 � Nmne and addn�ss cf curnant ownsw ,��✓ f,�y� �-r /a Praperty Da�iptlon: Lot size: � TownshiP� __,:___ Subdivi�lon. �f ��a� �S� � s �7 � �fr�ctf�rts t� th�'ropssfy (lndudln� road n�n,a� ar,� ��,.,titim.��. ----. �t �._. � , � � �s 4) WmRm:ad Usa snd $tryatura DoscAptlon: �nswer � af the follawing questions: a} propased �u�(��x1 stln9 iy�a of Shuctura. _ �h �(� �� '� _ Width: ��� Dept�: �� ti. b) Number of Bedrooms: . Nurriber of 000up�rtts or peopl� to ba sen+ed; . o} Basemer� Y�_,,, No�Will there ba plumbing in tho besament't �' - • d) c5arb�ge Oisposal: Yes ;_, No � , --- .. S� Walar eupP�Y TYP� �'dvate.�. (n�w,�o�' ealstln '+Rre an wolis o a alni p� �' P�'��° '- Communlly�_,, SpMnQ,_ Y, r dj np pro e Ye9 No,_ tf y�s, p►a�e indlcate approxlmate lacation on tha ,slte ple�i. , . , 8} Qoe� Your p�+oPertY contaln proviousiy Identtfled Jiiriacil�t9ottal watlanda? Yas_, No /� P6EASE MOTL'I'W�t FOLLOWIN�� ' ' ' �� PLA7 OR TW� P�tOp�i7Y OR 91TE P4lN NIUST B� 8U8MITTF.a WITH T�IIS APPLlCAT(pN, D PROPERTY LlNE� ANO CGRNERS IVIUST BE C�ARI�.y MARKED. , ➢ TH��PROP09Lit LOCA710N OF ALL STRtiCTUFtLB MUST B� 9T,�D OR �I�LGQ�. ' A THE S�T'E MU9T BE READILY ACC�991BI.L FOR AN I�VALUATiON HY THE HEA�,TH D�JPqR'PltflF.�' STA�F: ' I hereby make aQplicatfon to the Pecaon ,Caunty Haalth Dep�rtm�nt for a site evsluat(on for tha On�stt,� sewaBe dlsposal avs�bem for the �t�ov b@d propecty, ! eQree that the aontents of thia appllaatlon ere tru0 arad tspr�.sent the maxlmum {�� �ov�e p^ cn the,property. l understand�jtt�..si�e ts altQrod or the intsnded use changes, tl�a pormit shalt /" /D � -D % D�te PC}�iD� rev. 0�127/02 ► � �M �' � ���� � � �� a��� �� . � /''�( ���� �JT�q'�^� . �. w � -1,' ^�, `iJ �" �� 1i Ji '-� ��.a-��,�-�-+�e��.,�.I1 I�-+���.Il� Applican� Location: �x Map ` � ' arc�el ., , �U! �@{,I V i S�I � lil �_ � 'h��s�e-S�cfiian_Lat :: �pr�vesffient ��s�mit - � ��smat �Ta�ad �o�,/ ��ve'�s� �+To �iiPation . Type �of Facility: �i,c�i� ��rc��1,,, cJ���PI 1`. r�, New / Addition �ate� ���p�y Wr l I ## of Oc�upantsl��� # of Bedro �� . r ujz�ted Daiiy Flow 31oc1 g.p.d. Proposed Wastewater System: (�A��}��i ��_ � � Type: � L Q Proposed Repair: (' x�vP►-�-�; �y,� � � Type: 1-�_ Permit Canditions: -�\ i �� Si� ��.�'i . Owner br Legal Re}�resentative Signaiure: Authorize3 State �Agent ��,� i � 1� The issuance of this pemut by. the Health Department in does not guaraatee the issuance of other pc�its. It is the zesponsibility of the' aPP��P�Y ownes to in smce tha# all Person Co�mt}► Plauning aad Zamng and Bn�ding Inspections reqtvrements aze meL This Improweaaent ��rmit is s�jecf to revocation ii the sife pIaa, plat or the intended use c�aeeges. The Ymprovemeat �as�it is not affe�tesi bp a cii�nge in ow�ersiup of the property. This permit was issned in cflmq�liancs.with the provisions of the North Carolina 'Zaws arid Rules for Sew�e Treatment and ]]�iisnosal Svstems' (15A NCAC 18A .1900). Neither Person �onnty nor t3�e Enairvauaental Seaith Spes.ialisi' warrants tiAat the septic tank system w�11 cantiaiue tn fnnc�on, safisiacton7y in tiie futnre or'that the water suQply w�l remain: potable. - -. . _ . ' ' . Aa�thox�i�#ion �D Consirr�ici �Bs#ewater SYsgem (]�e�aresi far ��iding Pers�aat) * SeE site plan and additional attachments (s��. . Proposed Wastewater System: (�x�r� IPr� ,-�,-��Q � Type�� Wastewater Flow �� o-g:p.d. New,� Re�air Exgansion� . . Soil LTAI�: __� g.p.d1$ 2� Type ofFac�ity: ��_��no�. '�rrl. �sc� �� Basement � Yes No ' ' . .. �aste�vate� Sysiean I�e�n�eynen#s � �ank Size: Se�tic'�ank: lo� g� Pnmp Tan�: -- gal �Grease Trap: — gai �rai�eld: 'Tot�l Ar�a: � sq iit -Totai Leng#h � ft � 11$�mnm Trenci► IDept� % 8. in 'T�e�c3i v`�'idtd�. 3� �'�'in�n� Soii Cover. �.. in 1�1'ammim� Trench Se}Daaaatitan: � ft �istrs��taon; yii§trib�a#ion �o� � Serial ��stnlbntaon Fress�re Manifoid Specifications: '�i����l �I� �Pl�n �►'1� C���r���i��n� C��r-c�t't�-� E/lv- Fie��i �'�%�l7`l�(� Anti�orize� State �g�nt � � a , PerBrit Expirativn Date: Date: The type of system pertrritie3 is Conventionai Ac��te3 Alternative. I ac��t the specifications of the P��- � � ��e�r/�.a�bal �8�pres��#ative: � Date: � � � U ' pCED rev. l 1110/OS ��� ? �� ���� �� � ~ �- � � ��� 1� IG �.va �r o an�a �e �. ��.Il. IE—� m.m:Il � 71a SITE PLAN Name �n Tax Map # 1"�O Parcel # 13 I S 'vision CO`Cr��C1�����1 _ Section/Lot# 1-"IC Y�x� . ��l�'�[- � 0�2 ��""1 Authorized State Agent Date System componeats represent appfoadmate conmrus only. 7Tie contracrarmusrtlag tfie system p�ior ra begianing theinstallatioa m insure thatpmpergrade is maintaiaed �.\� �.'-EiXiC�S i ��r�-k��� ��s-� �, �, ,s�a\\ �s-�e.rr. '�n i �i Ot"l� s-�cr,� C�r,-�e� �1� � �?-7-1�1�?D � � ,e��,� �� Y � _" �,�� � l i ,' � ) �, � . ��� � . .� � �� �1d� � ��`�'' � �. � �: � �� � ��� I��.�..�-�� -Y-n-r ��.�.�. 7�3L�.�.1L�.�. � �tr � �� � ��3 � NJ °tLrW�° W' lli`Ill�1110� ' � O�O A l�Gi. � ��cOC�4t� ° � ��`���t� ,� / 7 G � a� �_� 2 . A�7g7�ICatu. Fi2GGi0A'� N�MPS � ' ' ' Lnc3�ldl�: v�d�� r/Is '� o.�' C�/o,.; sa.�,� Loa� e�/d . .. . � • � ��. ' �� . . . . . . � � . S�strrm Typ� (ln Ac�arda�c� 1�V� Ta�i� 1#a): _ �o� . . � `i'Y31� SV'S"i�di ; � �E�� II�R�T.�1..L.� � lM Ct�e�P�.ldl�l�� l�dli�i .�►i?4�9..l�,��..E N�E�i}-t � �'�►i�t'3�.d.A�, fi��L ST,�?Tt1T��, RLiL�S FzJi� S�9".ee�.�� T�T�IEi�i'f ANdCS 3Jl�Pf751AL.; � � APat3 AL•L � C1JN�3lTiCIlo15 • CJI� '� T'�E 1��'�tfl��i° P���t �,N� Ct�(� ,iI�UGTIC}h1 • �4UiH�JJ �`T1�JD1v . , • • , � � ......�. :...�. . � . ����a 7 . . r . � Auihori�ed 5t� Ag�rrt �r ' . . Dai� ' , ltn�#all�ri �y�____� � ��-1 S _ ' ' D�: ll�/ S�o7 - - ._._ . � �,[ �%p Navst.�/.`PSdi,9~��' �� '" . .. • -f-r.�.� � �i�s��cd+o�.. •. . , •� . ,. �.� __, • . / - �L�,� r.- 9l.' . �i nt Z• - • %Q � ' . Lr.�. � - 81 ' � Ll,� y - si, T',�( _ 3/ 3 �° l : �,�vc..�ra•�•l G� � � t� � ` " � ��� �.�1�� ������+�� �i�'���� ��c� �� R �� . . T� Ni�� � i� , .Yo Pa�� � / 3 ./ � � . 8ys�sn Typ� (i'abie �2� ?�� . O�nrned}���tlic�# Fi.c.cda,�., f./ o�,..ts . Sa�bdivis�on C� �� 1•�-( Es,�cs . Addi�esslt..or�#i�n Nv.d �L ,h r��s �d �? � ��ff'h� ` L� � : /7 �- � f7/l. �o�onl'•�i E'S,�f'��-s � G�o.. li� tn C�/�•I'.�,C � . . ' f� ' . , '•, 0 ..��. • . :;�.;'.'::�::.::..: . . :..:: .:: ::.. `��� ..,�.:.�� . ::�;.. .:*... •::: � . -.ti�.-�.:� .:: :..::: _-��.':�'.�.:; �.:: �': `:::: .....: • :,. ��'�� : ���:�.� ��.� �� ..........v:::.�<.: ,.;.:..:,:::.,.;..�,..>,;::..., . . . . . .:. ., _, .. ..:.: .: . ....:.... .:. . :.. . . , .. . .:. .. . ... .. . . : . .. . . . . ..:. ..; ']JtD:<�9,]li]L�.4�?`n.,r,r,x„�% . ..T. ..., ,-�-�y- . ...•:.::..::. .. ... . . .---�r..t..4'Ca3t�1i:�.�1i:11•':�.1➢,_ ,1p, ... � .,. .�•. .......:.:.:.:�., �"• �a�•�3y — . ..... .... .:..•... ....:.:..::.... �. �:•.' .,. .. ��� �JLYY.r �".'L' Y9.lYA&. A . �'1��L�r1�� �1L'i� �� A t�'Ls� x�.� �C n'ta � V��Jl� YY L' �L� l7d 8.'L' . n'ra 3� 41� Tax Map �_ Applicant: ��: Subdivision: ��; Location: 1�1 � . ra� Parcel # �_ .. Townslup: — '� r� (` � 0 –c-\o - �C` . Lot # 'Type o� W��er 5�npp�y: �c Individual _ Community Public Requir�ments: Site Approved By: `�d � � ��¢o ��� Grouting Approved By:�,�{ � i 120 (�n Well Log: '� t 1 I Zo 10-� Pump Tag: � .� Well Tag: ' Air Vent: � � Hose Bib: � �' ' a � Casing Height: Concrete Slab: � � Liner: 'Installed by: Depth set: _ Grouted: Date: Water �ample: Well Driller: r � Well Approved by Date:� 2—o *�*�See Att�ched Sfte Sfl�etch*�*� . 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: PCHD rev O1!27/0� � � � � f ��J10.� �� ' D� flD � 3267 �-t x - � a o � Barnette Well Drilling Inc. ������:: IE��n����.��.�.]L: IF���.3L�.I� , �� ��- I �/ -!a � � Grout Log Owner: ►�.f �C e�-p''� �-}-a f^ e} Tax Map I��n Parcel #�_ Location: Subdivision: � n 1 nn � u( r�,��3 �, LP s Lot #�_ . • Well Constraction Distance From nearest Property Line (Minimum 10 feet) ] D Distance from Septic System (Minimum 60 feet) � A Total Depth: � ft Yield: �� GPM � Static Water Level: � ft Water Bearing Zones: Depth 1 f� P� ft 2 �l n ft ft ft c��g: 6 1 /4�� Depth: From . n to � ft. Diameter: in Type: Galvanized Steel Weight: Thiclrness: � � 88 Height above Ground: ,� in ; Drive Shoe: Yes No Any problems encountered while setting casing? Yes ✓ No If "yes" give reason• Grout: � � Neat: Sand/Cement Concrete GravellCement �. Annulaz Space Width � inches Water in Annulaz Space Yes No Method of Grou� Pumped Pressure Poured Depth to Ft. Materials Used: - No. Bags Portland cement � Weight of 1 Bag Pounds If mixture (sand, gravel, cuttings) - Ratio to ID plates: _ Yes _ No 4 x 4 slab _ Yes _ No Liner: � - <.� � Depth: Date Installed: Grout: Installed by: _ Drilling Log Location Drawing From To Formation � � v`b-�u r �.- . .. S hG � p Z o rt o� r� Lo���G�s3u�J , � � �� . I hereby certify that the above information is correct and that this well was constructed in accardance with regulations set forth by the Person County Health Department. Signature of Contractor �-�Z __ i7 ID# 3267 Date I' �- ��-� 7 . Pump Installment �p ��ila�on con��c�r Bamette Well Drilling Inc. State Registration Number. 3267 Pump Depth: n r� ft Static Water Level: � ft Pump Make & Model: Red Jacket, Grizzlv Pump Size and Rating: ��hp � P gpm I hereby certify that this pump was installed and the well head completed according to the Person Couniy Well Rules in effeet on this date and that a copy of this record has been provided to the well owner. Pump Installer Signature ��n l�.�'.��P� Date: �� � i� � PC�ID rev O1/27/04