A40 184Person County Health Department
Sewage System Improvements Permit
Date:���This Permit Void After 5 Years Permit #.�%� ��flU
Owner: SR# �C%�/
LOC8t1OI1�D1I'CCt1Oi1S. S J V f"1
Subdivision Name: +" I,ot # _. fg_
Lot Size: f�...�, �ti ��� Type of welling:
Water Supply: Private: _� Public: Community:
Bedrooms: .� Garbage Disposal
Basement - Basement Fixtures
INFORMA D BY , �
$���: o er or a�tative
REPAIR: REEVALUATION:
-------------------------
Size of Septic Tank: ��Q�� gallons Size of Pump Tank: �
Nitrification Line: /f �iC ? �'
��-s=
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump L P�mp
Remarks: � .�„ ,�,.nn �►� (� c��
� � � � � � � � � � � � � � � � i � � � � � � � �
Date Well Approved: Well should be 100 f� from any sewer system
BY Sanitarian
Date S a e S s�rove •�" 2 S-�7 �
BY Sanitarian
CATE OF COMPLETION
Contractor. ! L L 1
Sewage System location, installation, and protection must meet state and lceal
regulations. Septic tank should be pumped out every 3 to 5 yeazs and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and
nicrification line must be inspected and approved by a member of the Person County
Health Department before any portion of the installation is covered and put into use. If
the site plans ar intended use change this pern►it is subject w revocation.
(G.S. 130 A-335F)
Location of sewage disposal sewage system sketched on back.
(OVER)
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NOTE: Make sketch of installation showing lot size and shape, location oi house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
�= at later date. Note location of water supplies on adjacent lots.
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Person
Date:S� 2�- � �
Owner. �
Locati uecti s:.
�
Su 'vision Name: I
Drilling Contractor: _
�f � l d �n
County Health Department �
Weil Permit . �
Permit oid After 5 Years �
' S #� -� �
—z�,tia
' Lot #
WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollution '^
Total Dep� Ft Yield: W GPM Static Water Level Ft
Water Bearing Zones• Depth FG FG Ft
Casing: Depth: From�_to L� Diameter:�Inches
TYPE: Steel Galvanized Steel �/
If Steel, does owner approve: No
Weight Thickness: � Height Above Ground: Inches
Drive Shoe: Yes No
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason:
Grout: Type: Neat S�[Cement Concrete
Annular Space Width �L,.� Inches
Water in Aru►ular Space: Yes No
Method: Pumped Pressure Poured
Depth: Fmm�to Ft
Materials Used: No. Bags Portland Cement Weight of 1 bag, lbs.
If mixture (sand, gr�vel, cuttings) - Ratio: to
ID Plates: Yes No
4 x 4 slab Yes � No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT �
THIS WELL WAS CONSTRUCTED IN ACCORDANCE W1TH REGULATIONS SET �
FORTH BY THE PERSON COUNTY LT DEP RTME . �
. 6 I�
Signature of Contracto Date
G�J.-r'.C� �
Sanitarians Signature
Sketch well location on reverse side.
�,.` S —Z2
Date Issue
Date Completed
NOT,�: Make sketch of insta.11ation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be
located at later date. Note location of water supplies on adjacent lots., �
(1) . (2)
Applicat(on Date: �%'Z 7��
Amount Paid: ___�i //i/
Receipt#: "� L
Tax Man #: � "' �
ParcEi #: ' �
•`��'?:�� ���� ��
- ___._ � � g..TI��T'I� �
�aa�aa-�.aa��-•--� .e�m�.alL �-�mm71.�IIEa.
APPLICATION FOR SERVIC�S
IF THE INFORMATIO(d IN THE APPLICATION FOR AN IMPROVEMENT PERIUIIT IS INCORRECT. FALSIFIED,
CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT i�1ND RIUTHORIZ�4TION TO
CONSTRUCT SHALL BECOME INVALID, �
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/A ` j �il, 2 j�1
1) Permit requested by: (Own r/a ent/prospective owner): l\/1 � �e-i
Home Phone:�3'����4�58 Address:
Business Phone: � -
2) iName and address of current owne�:
3) Property Description: Lot size: Township:
Directions to the property (Including road�ames and
Subdivision:' Lot# �
0
4) proposed Use ar�d Structure Description: answer each of the following u stio s:
a) Proposed �/, Existing , Type of Structure: S W Jl1l �- '�- ��e� Width:� Depth: � Z
b) Number �f Bedrooms: �,_ Number of occupants or people to be served: �_
c) Basement: Yes_, No �Will there be plumbing in the basement?
d) 6arbage Disposal: Yes . No �
5) Water Supply Type: Private �(new _ or existing�, Public,_, Community� Spring _
Are any wells on adjoining property? Yes_ No _ if yes, piease 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 QR SITE F'LAIV MUST BE SUBMITTEfl WITH THIS APPLICATIOM.
➢ PROP�RTY LINES AND CORNERS MUST BE CLEARLY MARKED. �
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAa(ED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HE�ILTH DEPARTMEiVT
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 shall
become invali .
''i�'�. \ �-� ��7-��
Owner or Legai Representative
Date
PCND, rev. 06127/02
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(AC�CESS & SEPTIC �
I SYSTEM ACCESS)
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T�x M�� . � F�rcel # ►
S�aihc!'ivis,ion �� � i i( %
Fh:�;s�e Se �rion Lot # i
Applicant: �(�`G 1it�..Q � /LI��''i
Location: . , , n 1 , , „ _ - � •+ -
S t�t •—� f-��rh�, � 1/I I, i� p�Y .�--� ��r���l���e.-
Improveffient Permit
Permit Valid for � Five Ye No Ezpiration
Type of Facility: (�' �� New � Addition Water Supply �
# of Occupants � # of Bedrooms Projected Daily Flow � g.p.d.
Proposed Wastewater System: �,���
Proposed Repair:
Permit Conditions:
Owner or Legal Representative Signature:
Authorized State Agent:
Type:
Type:
Date:
Date:
The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met This
Lnprovement P.ermit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rule�or Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental �ea1tL
Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain
potable.
Aut�orization to Const�uct Waste`vater System �Reqnireai for Building Permit)
* See site plan and additional attachments (_1.
Proposed Wastewater System: i 5� Sr pvr i Type-�� Wastewater Flow �6�' g.p.d.
New Repair %� Expansion Soil LTAlt: ►�� g.p.d./ ft 2
Type of Facility: S' S��✓ ✓yr Basement _ Yes � No
Wastewater Systean Requirements
Tank Size: Septic Tank: !��� gal Pump Tank: gal Grease Trap: gal
Drainfield: Total Area: sq ft Total Length ft Maximuin Trench Deptai in
Trench Width
Distribution:
�C
ft Minimum Soi1 Cove�: in
Distribution Box �. Serial Distribution
Authorized State Agent:
Permit ExX
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Date:
Mini.mum Trench Separation:
Pressure Manifold
Gtlt°� � �I
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Date: C0�3���5�
The type of system pernutted is � Conventional i Inno ative Alternative. I accept the specifications of
the permit.
Owner/Legal Representative: Date:
�'.� '' a �
PCHD7/30/2002
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