A40 20Appiication Date: 7� � 7�� �
Amount Paid: l�a
Receipt #• a G 3 `l
�� �
3z ����5� ���.� ��
-�- � � �� `� �Y
������.,._._-,. ��.��.a ���.���
APPLICATION FOR SEi2VICES
r -�
Tax Map #: � � �
Parcal #: � v
��� �
� �.�"
IF THE INFORMATIOIV IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED,
CHANGED OR THE SITE IS ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID.
1) Permit requested b:(Ownedagent/prospective owner . ,
Home Phone: S�- 3 3 6 Address: G O a v� e f S � c�
Business Phone: - 3a ��� � I I�, � C 7�� ���r�
�� e
2) Name and address of current owner: �
3) Property Description:
Directions to the prope
4)
Lot #
1 �O 0
Proposed Use and Structure Description: answer each of the following questions:
a) Proposed _, Existing �ype of Structure: ��o�n5 -� Width: Depth:
b) Number of Bedrooms: 3 Number of occupants or people to be served: 3
c) Basement: Yes_, No ��Will there be plumbing in the basement? 1��_
d) Garbage Disposal: Yes , No f
5) Water Supply Type: Private new _ or existing�, Public_, Community_, Spring _
Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the
site plan.
6) Does your property contain previously identified jurisdictional wetlands? Yes_ No ✓
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. _,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAfCED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal
system for the above-described property. I agree that the contents of this application are true and represent the maximum
facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit sliall
becom� invalid. � n
Owner
Date
PCHD, rev. 06/27/02
RECOMBII�ATIQ?� SURV�Y FOR:
-�� �IM �ORRO�ti , ��TALTER � • ��� � �
' � T n;D SURVEYOR ,
� �I PROis SSOLTH LAMAK STREET
j- E
� S � � RORBORO, NC 27373 T� MAP A40 LOT 20
I� (336) 599-7676
� PLS-3250 FI,AT RIVER TOj1NSHIP `
- PERSON CO•, �'.C.
� I g�12/2Q02
�
sR „4, �
IFOR A T07AL C� 1.48 ACRES. �!J(�;TI-CO- �
N07c: LOTS A AND 5 ARE T� B� COMB�NED
� �Q��itk� i
NoT � s� II � a �
S03°�-g L � J� ;
��
D� I � ` �64.9e i
gyS PLAT R� �`
scr'�at strtrv� �s •�
�°� sou�i�m��s � � � �
ox �—
CATEU AS DRa�` �T . /� �
YAGE 11l � �� C I
:II313EL' AS 1: 20.0�H Y/ � 7^,� (� V �
� y��' ORIGCIIiA�I.�SIGNATURE. I / � � •J
12TH DAY OF AUGUSi� I �� �%k� �
/ N ,
� s R. 1140 ,- 6g.18 3
� � � � � W ,,
-PRo� '� � � 6 0 R�, � � �1 � i_-
� �
-325� � 4 N�8 �� , � J
��,��or � � /4. 6 6 p� .
` � � 1 ,
' I /
II / ' �
,
, r, � e�
jJ�y prtD STGTS IS'0 ��� / � V � _ � .
R0� DAY ����g� I �.J ��� � .
OII:v IN �S 1SfH DAY I / / ...
� pg SEAL
:. /
, I� / /
/
• / / /
' ^ 1 � ='��t-G✓� I �
i��Y PUSu�
NOTAR . ` / �
� �V� /
�- �(. � j �, 7� �C I� �`� " ..
� ca�ssior er.ea�s �� ,�,�� j / / � CQ
'�' � `_ I'�
� �G \,a �7
! I � N �
�v�os. xu�� � �
�'. � oa�tto�cu�c: '�� l..J� c r'7
i'fg5 ► S[JBDIPIS[Ox OP IAND nT� / . Oo �
6 YUN'.��� T�T fl6S 1N 0%DIlV1NC6 �
ys o° TaT`9s ✓�
AG'[8D iN l PO%RON OF COUNCY OE �O ���
CFitS +��� � T� lN ORDINANC6 � . .
�o°� V�7 �'� 6',
?OIIA��� P�� OR P�HCE= OF IJND I x� ° � �� !�
ff IN ID�TII'�0^r CH1NG8 ��6 gIQB[L: 1 �O � �� V
G 50�, isT66C0o�� �
�� �
,�,��oL�. ��w,aRc t ��`� �TC� �� ��j�
N.
• oF ►tio'r� u�vai�o�� �
lY1 'IHS DSFQ�'ffION OF SQBDIPLSI�N: D.�. 2 I Z/•5 /� �/
JF AVA66B� TO THn SQHYSYOR L SO"�•6
��
�g{y 79 yA[g A ➢EI881@:AflON �P1S1R� � I
�qUyy: lE'3I'if 1S 70 P� -
� ��
• I�
gy �pORDIN9TE COHPVfA7f0I: YEfB�D I .
ISE•
IORiZONTAL GROUh'D DIS[9T<CES U'•�S Ii .
�py�A GE9DEf[C SURVEY HOhV1�h"L�IIi . �Or
CkIIS PROP&`�• lil J �./
I� , C0�
�-��, ; ��� ���� ��
' .�-�- C� � �1�T��
�iaa�n�-��n.na�n�sa��.� ��aa.m���n.
WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: � Pazcel # � Township
Applicant:
Subdivision: Section: Lot:
Twe of Water Su��ly:
Reg.uirements•
�IndiPidual Communitp Public �
� ��,�,,� �,,,�¢� �;`'
�� ! �'�
Site Approved by �� A-�� O r�` ��,�n �`
Grouting Ap rove by � � i�' ��v•"��
Well Log �,,_f� i,t- �--pt�/ 2 V� � �t.c��
Well Tag . � �"'''�- `
Air Vent `� �C�
Hose Bib �� �' � � C ( � ��
Concrete Slab �� �l,(,�.
Well Driller. �^�v�
Well Approved By: Date:
'�°5ee Attached Site Sketch*'�
Wells must be 10 feet kom 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. 09/07/01
�� s o�oo� � y��
�._, :. � ���$.� ��T
�' � � ��� � � ' � Gv�! ( 1I � n�;�
���s��„-„-„ ����.� ���.�-�� D�o o � � -.s� a
Owner: �
Location: �
Subdivision:
Well Log
Tax Map� Parcel # �
Lot #
Well Construcfion
Distance From nearest Property Line (Minimum 10 fest) tG fi
Distance from Se tic System (Minimum 60 feet) Ceo
Total Depth: ���U ft Yield: /S GPM Static Water Level: a� ft
Water Bearing Zones: Depth $O ft/�,S ft� ft ft
Casing:
Depth: From � to (g3 ft. Diameter: � in
Type: Galvanized Steel �
Weight: Thicl�ess: �8 8 Height above Ground: � in
Drive Shoe: r/ Yes No Any problems encountered while setting casing? Yes � No
If "yes" give reason:
Grout:
Neat: SandJCement
Annular Space Width
Method of Grout: Pumped _
Materials Used:
Concrete GraveUCement �
inches Water in Annular Space Yes No
Pressure Poured � Depth � to a o F�
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
Drilling Log
Location Drawing
From To Formation
C�
So c�� S
O U
�
s
v ,�
1
�'ox�s s {b,ce �
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 Contr ctor l� ID#�� 8 Date 7-� d a
PC'�iD rev O1/16/02