A40 185,4anlfcation Date: ►a'`1'D�
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APPl.lCA7iON Ft3R SEiiVIG"FS �
'IF THE INFORMATION IN i'HE �►,PP!_lCAT10N F�R AN IMPRONEflAENT PERlIAIT iS INCORRE�''�', Fa4LS1FiEJ
C�{A,4PIGED, OR THE SITE IS ALTERED. THE�I THE IMPfiOVEiNENT PERMII' AND AUTHORI7�►TI�N TO .
CON9TRlJCT SHALL BECONE INVALID. -�
1j Petmit requested hy- Owner � entlpros�ive ownerj: L dit 4��yn s�r�c�`i�z-,Ba��
Home Phone: 3'3 t- 3�a �1 Address: O D �
Business Phone: — �� , af IQ �,. .y' �
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3) Pt�operty De�criptIon: Lat size: /i �%8'a�.Tawrtshlp: � Tfli�rN,r Subdivision:� I�d.�Ur� ����tc��Lflt#�
Dire�fions to the property (lnduding road names�and numbers): /�ur �/a m;i/ n--.5'cL•� ��' R�rL�-p a-�.
4) Proposed Use and Structure Descriptlon: answer eaci� af the follnwing questions:
a) Propased X Exlsting . Type of Struc�re: s.:..��/o_ c�� d� Width: .� `/ pe�th: �`'r�
b) Numher af 8edroams: _�, Number of acs��pan " ar peopie to be served: � •
c) Basement Yes . Na �, Will there be piumbing in the•�aseme�i?
d) 6arbage �isposal: Yes . Na �
� w'�' �PPI� TyPe: Privabe �(new _ or e�lstinc,�). Public � . CamrnunitY_,, SP�9 � .
Are arry wells on adjaining property? Yes� No _ tf yes, please indtcate approximate lacatiari on the
.site plan. �
� Do�s your propeity cor�in_prsviously ide�fiied jurt�dictional w+etlands? Yes_ No �
Pt.�A►SE NOTE THE FOLLOWING•
➢ A PL�►T OF THE PROPEiZTY OR SITE Pt.AN MUST �E Sl16M17TE� W17i� 7'EitS APQUCATtON.
➢ PROPERTIf UNES AND CORNERS NUST BE CtEARLY AAAR4�. •,
9 THE PROPOSED L�CATION OF ALi. 9TRUCTURES 11AUST 8E STA[��D OR FLAGGEi3.
9 THE 31TE AAUST �E RE�DILY A�CESSIBLE F�R �1N EVALUATlON BY THE HE�►t.TH DEPARTMEiNT
Sl"AFF. .
I hereby make applic�tion to the Person County Health Deparlment fior a siie svaluatian for the an-site sewage dispnsal
system for the above-descrii�ed property. 1 agree that the coritents of this appiication are true and reQresent the m�cimum
faciiiifes to be placed an the properiy. ! understand ifi the s�te is aite�red or the irrte�ded use cnangea, the permit shaii
becotne irnalid. •
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Applicant: ��,{Q� ����f'Z
Location: . � , , . - � - — „ - +L - 1 � . _ ,
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Tax M�� � Fa,rcel # �
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S�u�hciiivis�ion �� L '
Ph•�s�e Section Lot �"
Improvement Permit
Permit Valid for Five Years No Ezpiration �,p
Type of Facility: ,� New y� Addition Water Supply �
# of Occupants t�Q of B ooms�— Projected Daily Flow p��0 g.p.d. �
Proposed Wastew er Syst ?1LiG�i�1 . Type: "
Proposed Repair: iM/l-�?l�tA. Type: :�
Permit Conditions: � S� �-2�L1
Owner or Legal
Authorized State
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The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit 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 `Zaws and
Rules for Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain
potable.
�Authorization to Construct Wastewater System �Required for Building Permit)
* See site plan and additional a#achments (_).
Proposed Wastewater System: �lV`2r1�-�7AZR l Type�R Wastewater Flow �TO g.p.d.
New � Repair Expansion Soil LTAlt: ► 3� g.p.d./ ft 2
Type of Facility: B� �PS• Basement _ Yes � IVo
Wastewater System Requirements
Tank Size: Septic Tank: (�� gal Pump Tank: gal Grease Trap: gal
Drainfield: Tota1 Area: �� sq ft Total Length ��O ft Mazimum Trench Depth � in
Trench Width 3 ft Minimum Soil Cover: �_ in Minimum Trench Sepazation: � ft
Distribution: Distribution �
Specifications•
���
Authorized State Agent:
Pernrit Expiration Date:
� Seria1 Distribution Pressure Manifold
i�nr�� �,%t � �I.rr,v✓t �1r� i�1�i ���inl� �lt'�)
Date: �� � ( � ��� _
The type of system pennitted is �Conventional Innovative Altemative. I accept the specifications of
the permit. � '
Owner/Legal Representative: �o -�f.� 2�. -���o Date: .r/2� 72• ��
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PCHD7/30/2002
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S�'1'�. SI�'T��
Tax Nlap # l' ,� � P cel #��
Section/Lot#
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Date
System components represent approximate �contours only. The contractor must, flag, the system prior to
beginning the installation to insure that propergrade is maintained
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,�' f Well Log
Owner. ,f���C�o S�CI�. e z • �U �e�-�
Location: - 11
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Tax Map/��� Parcel # ��S
Well Construction
Distance From nearest Property Line (Minimum 10 feet) `G
Distance from Sepric System (Minimum 60 feet) � c�
Total Depth: �_ ft Yield: �_ GPM Static Water Level: � ft
Watet Bearing Zones: Depth %v'-" ft/!C� ft ft ft
CSS1IIg:
Depth: From Q_ to y� ft. Diameter: ��S� in
Type: Galvanized Steel ✓
Weight: Thicl�ess: �_ Height above Grounci: �� in
Drive Shoe: / Yes No Any problems encountered while setting casing? _
If "yes" give reason:
.�.� 1 SQ p Frc y
� 1 rap�;,
1
�,�wst , _ _ _
�QidE
Yes •/ No
Grout:
Neat: SandlCement Concrete GraveUCement ./
Annular Space Width inches Water in Annular Space Yes No
Method of Grout: Pumped Pressure Poured .i Depth �_ to �a Ft
Materials Used:
No. Bags Portland cement !�- 1,�+�. Weight of 1 Bag � Pounds
If mixture (sand, gravel, cuttings) - Rano to
ID plates: .lYes _ No 4 x 4 slab �Yes _ No
Drilling Log
Location Drawing
From 'I'o Formation
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I hereby certify that the above information is coirect and that this well was constructed in accordance with regulations
set forth by the Pers n..��n�}C-H.e.�ith Departmeg .
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Signature of Contra '� ID 7 z O Date 3��~a3
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Applicant:
Location:
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S'Uh(�iiVI:S�l�11 �
P�has�Secti,o�a�'Lat f
�erat�or� �Pernn��t �
r � System Type (In Ac�ordance With l"abie Va): . �
THIS SYS'iElVi HAS� BEEM IidSTa4LLFD IN COi1flP!_l.�►NCE. �Ii1TH APPLICABL� R9�RTFi
CAROLIMA GENER�►L STATUTES, I�ULES F�R �SE�IAGE'TR�Ti�iENT AR1D �iSPOSAL, .
A(dD �►L.L CONDITIONS ..OF 'i"FiE Ii1APROVE�E3�Y PER6IAIT �D. �COIdS'�RUCTI�N -
�AUTHO Tl N. . . . � � � . . . . ..�.. ..� � . : .
. . .. . . . . . � ��-;�`�'�� � � � �-
- A rized State Agent � � � . � �� . ' . • � Date . �
Instailed B�: �� U IG�� • �Date: � ���^'� �
. . . . . � .. . . .. . .
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/E S���G ��l� iNS�����N ��E��S3` (�'�e �1- �
Ta: MaQ � "�� �arca! # �. � System Type (Tabie �a)
OwnerfApplicant �ubdivision "
�ddress/Location � Se�lPhase Lot #
St�ts 1D/daie ��t �'
Capaciiy. �p gai.
Wid�th
Depth ._
ft.
it�.
Tee and Ftier � ��� Trench Length , � ft
� Baflie � �/' Trench Grade
Sealarrt ' Trench Spacing •
Riser ifi applicabie) .� Rock De th and Quaii�tyy
Tank Ou�et:�Seai . � � � Dams/Stepdowns etc.
Permaner�t Marker � � - � Pressure Laterals .
� Purnp 'iaaaEs --, . . Hoie �Spacing -
. � iate ate � . o e �ze . -
. . � Ca�aci�ty. � . . . � gal. . . : .. Pi e Sleeve . �
�
� � . . � Wate roof /Sealarr� : � . .. � Tum-upslProtectors �
. . . Riser . � � . � . . Required Se#�ac�: .
Waier Tighfi . From Welis •:
�urnp �-- From Property lines �
_ C�ec� Vaiue/Gate Va�ve : � �-� : Structures/Basemerrts .
. . .. . . Anti=sipt�on o e � . - . � . .-- ii es ramage ays
_.... ... Floats/Swiict��es �� . . ...- . .. ..: . �. : _� . _ .- - �Surfar,e��UVaters
Alarm� visable and audible Pubiic Water Suppiies
F�ectrical Companefrts Vertica! Cuts ->2 ft.
Rate gpm � 1�later Lines
Approvesi Pump Model Vehicle Tra�ffic
�Ioc� Under Pump Ad'acent�Sysiems
Pump Removal Rope/C9�ain_. Easemerrtss/Right of ifllay
� Dis�ibta#aon S��m � �er
� Serial Distribution ' Easemerrts Recordezi .
ressure an' � pe or onir
Lowr Presscare Pipe � Tri-Partate Agreemerrt
Appr. Pipe Mater�al ar�d Grade �
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Goe�i��n�s�
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Subdivision: 'Fla+� ���-
'�10.,��. Secdmn: �� �
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��t�uaae�ea�ts•
Site Approved bp ��-�S 3-zs"��
Grouting Approvesi bp ✓�s -�-2�-�3
'Well. Log ./ 3-Zco-o� —
�Well T
Air Vent �
Hose Ps�
Concrete Slab
�� Dniller. � : � �-� � nl \'.
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� � At$ZC�YCf� SI� .5��1's�Ok
Wells must be 10 feet from property liues.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from anp building foundation.
Other conditions:
PC�ID, =ev 09/07/Ol
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W��L PE�t1VII'��
P�i.EASE SEE A'�"�A���YEI) I'I.AlV FOR WE� SI1'� L.A�X�UT
Tax Ma�p #: � Pazced # �� Townshig
�1PPlican� �; �� a �-� ��c'�L.
Subdivisiori:�� f ��Qr► � Section: I.o�
�'l�L� �s�� -� �`s� �� �' l��
'I'v�oe of Water Su�nlm �. Individual Communitp Public
R�c�uireffients•
Site Appraved bp
Grouting Approved bp
Well Log
�7ell Tag
Air �Tent �
Hose B� �
Concrete Slab
Well Driller.
Well Approved �p: I�ate: _
'�See Attached Site Skexch�
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systeins.
Wells must be at least 25 feet from anp building foundation.
4tiier conditions•
PCHI�, zev. 09/07/01