A27 41. � � 3,��,p7
Apaltcation Date: .I i"� �-D 4 p G
Amou�rt Paid: �',� a 7 � .
R�'� ti�460
�--._�� � �� �.��1�
��
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APPiJCA770N FaR 38ZVIC�
Tax Man #- � o� � -
ParcE) #: �
_�
!F THE INFaRf1AATiON IM THE APPLICATiON F�R AN iMPROVEiNE3�IT P�1T 1S INCDRRE�'T FALSiFiE�
C3�lANG�. OR THE S1TE' iS ALTE�tE�. THE3V Ti-lE IMPROVE3UIENT P�lT AND AUTHORlZATiOi�! TO
CaH1STRUCT SHALL BE�OME (N�/ALID.
1j Permit request�d hy: (Owned sntlpnas��e�tive owi
Home Phone: 9 9 Ms •W i K t w,��ddress:
eusiness Pl�on� Z�2 4 3�- 2o�}c (��m,,;.,�-�, �
� � �eo�►op�,e,o�
2) Name and .addr�ss of c�ent ow�er. L� a+h �.. � ti �
I�er�oA Cocc�-t�C Ga p�3 G�Cflmr�+4n i�l-y De�alop,nac
��: _+� '�' e.r� tie� 13. (�1 tttcttrLS
3) Property D�Qtian; Lotszze: 11.89a Tawr�st�lp:bl�y� ;tl
Direc�o�s ta the property (Induding road names and numb�rs): �
4)
5)
�
Ce.A�r� e $aRNe�f �1e� ra�.
�.B. � z�7
Lnt�,�_147
. +o MS•Wt6WaIM'6 ��C . -
t�roposed Use and Strvcture Descri�rtlon: answer �act� af the fdlowing ques�ons: `�
' a) ProPosed �, Existing �. Type of Strudure: i?. �il. tJl o b� l� i}� m t Wid#h:�� Depth: 't �S L
b) Number of �edroams �_ Number of ac�pants or peopie #o beJ�eqved: �_ �.
c) Basemer� Yes . No � Wtlt there be piumbing i� the basement? ���}
d) 6�bage D�pas�i: Yas . Na� �a . �
C � J�y\
Water SuPQhf TYP�= Privafe �new�� ar e�stin�PubiicN�� , S�ring .
Typ
Are any welis on ad�oining proQe�ij/? Yes�No _!f ye,s, Pi�ase indicabe appro�dma�e loca�ari on the
�sifi�e i�art-
D�s your properly car�ain previousiy idenfifi�i jurisdlctlo�i w�lands? Yes_ No � �
'� PLEASE NOTE THE FOLLOWING:
➢ A PL�►T OF THE PROPEiZTY OR S1TE PLAN NUST BE S1lBMITTE� WITH THIS AP�P�..lCAT10N.
➢ PROP�i2TY L1NES AND CaRNEitS MUST BE C�EARLY NARl�.. , � .
9 THE PROPOSE� LDCATION OF ALl. STRUCTUR .F".� MUST BE� STA� OR FiAG��.
➢ THE S1TE �AUST BE READILY ACL'�SSiBLE FflR pN El/qLUpT10N 8Y THE HEALTH DEi�AR'I�iEi�i'
STAF�.
1 he�reby maica apQlicatian to the Person Caur�ty� Heaith De�artrnent fior a siie evaivation for the on-siie sewage disp,osai
system far the above-described prepesty. I agcee that the car�tents of this aggl'u�tian are true and rep�sent the maximum
faciiiiies to be pia�d on the proPert�l. 1 undefstand if the siie is al�ered or the irrtended us� cf�anges, the Permit shail
became iriva�Id. �
awner
,
� c� [J�c.,��2� L�.d
.
Date
PCliD. �+r. 061271U2
I" I �� �"; � (�)� �T
- c <�� � - � I �.
� ,_., , . ._...... `.., ._. � l. � -__. �, �.
Tax Map # �a� Parcel # �i'QI
Existing Sewage System Report For. ✓ Mobile I�ome Replacement
Addition Type•
Requester. l n�o. 1����1;c�-.s � � HomePhone#3�-S�g�Byy9
33�� � M,,,-G `� Business #
iZox��� c� a�s��j
Location: 5"1 N� ��n � 01 �ve !-��l C�� -� c�n1�� an �'e� s��. oF ��.
"''� �uC. G'��.3 r n ���,
Original Permit Located: no Water Supply: l�n��-
Septic System Designed For: � Residential Business Other
# Bedrooms # Employees Other
System Type: �nvQnti� Tank Size: ��O Nitrification Line: ?G�` x 3'
Date Installed: � Certified Operator Required: r�a
On-site wastewater disposal system shows no visual signs of malfuncrion on 11- 1- tXi
Permission is gtanted to:�r ,��aco cS� w�a+�. � —
Conunents: �\ \� '�. S�a�-c.� C� c. �_ r�wa�- �.2���o.c�.
� o 0 5 �-t�- �nN,,. ���,Z
�'o,� wo 4� C�� � �F .r. ��h c
�
� I I���A� ��-�. �►i�.�..� a
Environmental �3ealth Specialist � Date: 1 �z�2-a�-1
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S 30 134.59'
�-� S 30° 13' 10"W T!E �"
141.58' TIE �PQ 7
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ROSE C. WHEEL E�O � -Q� i� � O X � 4
D.B. 451. Pp. � ��� � �(� � �}� � � � >-I CLAYTI
a � �` 2. �� �p 'V., i G�� �' CL INTO� E'�„�EELERy '
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er - � _ .
S 87•3u� 00" E 960. 09'—� 2 I0. 00' —� -=- -- __ -"`
2 0, Riyy AS FER T 2 1 1' ''� �
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DECK ACROSS LINE �� �i� �
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SATELL 1T . � G! `
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4;
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e� ���C' �'1 � A 17 0
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< PERSON COUNTY HEAL'TH D�PARTMEN"T
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # � �`1 Parcel # 0
Zoning Township � `' l
Owner/Contractor ` � < < Date r7— — �
Location/Address D Q-
S.R.#
�
�
a�
Uy�
c�
a
Subdivision Name Lot#,
I SEWAGE SYSTEM SPECIFICATIONS �
Size of Tank
SFD
Permit Void a er 60 m ! P�rmit Void if not'i�tainpliance with zoning
Permits may be voided if site is altered or intended use changed.
Well and Septic Layout by
Comments:
Date —�nst� e y Approved by
WELL SYSTEM SPECIFICATIONS
Individual ✓ Semi-Public Required Slab _
Public Replacement L/ Air Vent
Site Approved Required Well Lo�
Well Head Approved Well Tag
Comment� : , l , � � _ L �r � r '� �- �X� b+�
-�, -� �X.
Date Installed by ' Approved by
This report is based in pazt on Wonnation provided the homeowner or his/her representative in the application submitted for this pemut The
environmental health specialist is not responsible for false or misleading infotmation contained in the application The environmental heahh specialist
is also not responsible for concealed conditions on the property or for statements in this repoR that may have resulted from false or misleading
statements provided to him in the application Neither Petson County nor the environmrntal health specialist wazrants that the septic tank system will
continue to function satisfactorily in the fuhue or that the water supply will remain potable. ' c�amipro�permit.sam O 1/95 rev.1.0
ORIGINAL
.. y,'�Z,
.. . u`4�i'.
��--��* y � � ���� ��
�' � � ��� �l. .
1E�vaa-�� -m-T ��.,E.�,.71 IE'��,�.1L�IIs
Applicant: �_Q�
Location: ��
�
,.,,�.:;�
�
T��x �a1-,.��� e � ' �:�,rr_ :.I �
5��ri}eLiui��i.c��a
P'Ia�c:;;.r,,5�cti.��o�L.�'t �
. ganpr��ea�aeaat Permit
.
Permit Valid for _ 3E'ive Years. _ Nq Ezpirat�on "�
Type of Facilitg: ' � � New Addition
# of Occupants # of Bec�voms � Pmjected Daily Flow
Propoaed Wastewater S3�$te�m: � ._
Propoaed Repair: . . . .
Peimit Conditions: _
Owner or Legal Representative
Autlwrized State Agent:
>
'�ater �upply �
TYPe� .
Date: t � 1 �—c75
'Tho iasusnco nf ihis peimit by tho Health Deparhmaut in does not �guarantee i�e iseuanoa of other peunits. It is the responsib�ity of the
applicantfpmpeaty o�ner to in stuo that aU Peraon County P'lanning and� Zonmg and Hu�7ding Inspectione requirements are met Thle
Improvement P.ernuft is subject ta revocatton if the �ite plan, plat or the intended use changea. The Improvennent 1'ermit is not affected
by a'cLange in ovrnership oi the propertg. This geiwit was issu�d in compliance with the provisionis of t6ie North Caroi�a `Laws and
•�� j'or Sst�ee Tfreat eni and D,��sd Svsteras' (15A NC�aC.18A .1900). Neiti�er Person Coanty nor the Enviro�unental Health
Specialist warrants that the septic ts�nk eyatem will cont3nae to fanc3ion satiaiactority in the future or that the vva#cr auPP1Y will remain
'Antho�i.zation to
* See site plan and additional ctttachments
� Wa�tewate�'� Systeii (Required for Builaiag Permit)
�� � �}-�\�S
Proposed Wastewate,r System: �,S� � Type Wastewater Flow __g.p.d.
New R.epair� Eapansion �. So� I;TAIt: g.p.d.! $ 2
Typa of Eacility:. �.... • • �Basement �Yes No
- . '9i�astewater Syatem Reqnirements . .
Size: Septic T�: � gal .. PumP �ank: � C�. �. Sal' Grease Tra�: "- ga1
ld: Total Area: �sh aq ft Total Length Qx� ft Mazimum Treuch Depti��.x,��� '
'G�idth �f� Minimnm 5oi1 Cower: ���� fn Minimum Trench �eparation: 2 x� ft
d3on: Distrl�btztion Boz �Sea�l Dishrihution �Pressure Manifold
Specifcations:
+
Authorized State Agent: ��
Pea�it Expiration Date:
�
�
Dat�: �� i v-- o S
t �
The type of system pennitted is � Conve�tional Innovative Alternative. I accept the specifications of
the peimit. � � � .
O�vneslg.egal �Se�r�sentative: . . . � . . Date:
� � � PCI�D7/30/2002
�
.�1����� ������
— �_ . c� ;t�i .�71�'��
����-�,�,,.*.,,���.m.n �,��,�
S�'�. S��'I'��:
Name '�.a��,�e 1,�,11tG..� . Tag Ma.p #� ta�� Pascel # y1
-��isi�s 33�9 � �.�.��, � • Section/Lot#
4 � � • la- a-oy
Au�rhorize State .Agent . � Date .
` System corrrponents represent approxirrrate�contoasrs only. The cvntractor must, flag t'he systero�c prior tn
beg�nning the installation to irasure fhat pro�ergrade is »raintained
»�
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SCale: �� �� _ �O�
onk -Fs�Q. T�"' �
10 5a. �ar+�u�e.Z
. � � A�
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��� C?�'_ �G� � ��
W�.� . .
I'GHD, rev. 09/L/01
����` �� ���� ��
` _ � � � ����
�-'s�ra�-as-�maaa�n.a��n.�.m� ��c�.�.���n
T�x Ma.p ../ F'�rcel #
S�u�bciivision
Pha.se Section"Lot �
# of Bedrooms
Applicant: ��,�.�n�, 1�� \l��.s - �3?4 .r..,. C� .
-Location: �-;.,z -Ui �;,a �..�� ��.,.o �. �,..,.,.� 2a . .
Opera�oo� Pernnit
System Type (In Accordance With Tab(e Va): �I L 1 �j
THIS SYSTEM HAS BEEIV INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA� GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTIO[d.
AUTHORlZAT10N.
- ' � � 1-14-05
Authorized tate A nt Date
Installed By: (1.�5 -��1Q, Date: 1- Ig-o� �
�
'Ner�-,c, c�w� �-��-v�
PCHD, rev. 07129/04
��'iC i�iK IN����'�'i�N C3rlE�lS'� �'� Q¢�
Tax Map-# � Parc�! # � S�m Type (Table Va) _U.l.. � .
�WllE�AQQ1�C2f'it �o.. 1 ��,1�.$ Si�C�1V15iDf1 .,
AddressfLocaiion � SeclPliase _ Lni # � ~ �
,
pcfzd r�+�. 31'f 310�
.: :��.:'� .':.' �� � . ����..: .� . ..
.
,.:�: .. ��. :`.����'`��
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:'>� t.:(� ���Q::1���'�
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..:.. :.. .., . ..
. . ,_�..... . .. .. .. .
. . ....
. . . . �..•'�
"' . • :•:.
• ,r�r�,r,.nr- •::':'. , '
�.a�n:;;��:ar..a�a:. aam�:�:e�; : �•�o..,.¢ .
WELL PERNIIT �
PLEASE SEE ATTAC�iED PLAN FOR WELL SITE LAYOUT
�� �
Tax Map Az� Parcel #�i ► Townslup: C�►:�.�, U.��
Applicant: C'n�1, o,�,w� ��1,�a ,
Subdivision: Lot # �
Location: 57 t0 �(� c.�. . Ol�ve �-hll Grvcan. 7�lt u.a �,ve w s:a.�,
oF Sivr•
Type of Water Supply: � dividual
�ltequirements:
Community Public
Site Approved By: �/ � 12-! � �� � .
Grouting Approved By: (Z<C t2-a�-�
Well Log: CS 1a—a+-ac 5� "��
Pump Tag: � �
Well Tag: �
Air Vent: '
Hose Bib: �
Casing Height: �
Concrete Slab: �
Liner.
�Installed by: '
Depth set:
Grouted:
Date: �
Water Sample: �
Well Driller: IZm\u�. �: v\�' • � i�.�R' n �
Well Approved by: � Date•,
****See Attached Site Sketch****
Wells must be 10 feet from property lines. -Q�,_
���Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
,
Other conditions: �11 c; sls_�r�►. � 4.0��
Z, p�rk� � 1 b1,�,�. �_
� r�-c,r-►�. cae.�`
S��e .
PCHD rev 01/27/04
_��. Sf ���:� �� o�o� oo � Z3o4, t H :.
�----` -� �� � �w� ii�,iAm �vc
�C � �C71�T��Y c�
�����.�����.�:.ffi.Il ���.Il�� o�� �o� 12�� 6 — ��1
f� �`� �, f` Grout Log
Owner: �� 1 1-.� E W��k-�.� �MS TaxMap Parcel#
Locarion: M. j�
Subdivision: Lot #
� Well Construction
Distance From nearest Property Line (Minimum 10 feet) "
Distance fro e ti System (Mini 60 feet) •
Total Depth: ft Yield: GPM Static Water Level: �� ft
Water Bearing Zones: Depth ft ft ft ft
Casing: '
Depth: From � to �S ft.. � Diameter: � in
Type: Galvanized Steel �—
Weight: Thiclrness: $� Height above Ground: � 2, in /
Drive Shoe: Yes No Any problems encountered while setting casing? _Yes • No
If "yes" give reason: —
Grout: -
Neat: Sand/Cement ✓ Concrete GraveUCement
Annular Space Width _1�_ inches Water in Annu�ar Space Yes No
Method of Grout: Pumped Pressure Poured j� Depth to
Materials Used:
No. Bags Portland cement Weight of 1 Bag Pounds
If mixture (sa , gravel, cuttings) — Rario to
ID plates: _ Yes ^ No . 4 x 4 slab �Yes No
Liner: —
Depth:
From
Ft.
Date Installed: Grout: Installed by:
Drilling Log
To Fo.
Location Drawing
���.,�r�
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 Degartment. , '�
�
Signature of Contractor
ID# 2�J � � Date' � Z�� �'�7
�, _ Pump Installment .�
Pump Installation Con�-actor: State Registration Number: ��
Pump Depth: ft Static Water Level: ft
Pump Make & Model: Pump Size and Rating: , hp gpm
I hereby certify that this pump was installed and the well head completed according to the Person County Well Rules in effect
on this date and that a copy of this record has been provided to the. well owner.
Pump Installer Signature Date: PCHD rev O1/27/04
Type III (b) System Inspection Checklist
Tax Map Parcel #: � � PIN
Owner: (�ar�; � a rh e-�{- Subdivision:
Acldress: _ 3379 �►v�ora R� • Ph/Sec/Lot:
Location:
1)
2)
3)
4)
Establishment
a) type, size and sewage flow in
accordance with permit
Tanks
a) tank risers accessible and surface
water diverted
b) tanks and access manholes structurally
sound, watertight
c) sanitary tee(s) in good working condition
d) tanks pumped, cleaned out as needed
Effluent Dosin� Svstem
a) effluent appears clear, free of excess solids
b) required pumps present, operating properly
c) high water alarm present, operating
properly
d) floats, pipes, valves, disconnects in good
worldng condition, operating properly
e) conirol panel enclosure and components
in good condition, operating properly
fl Drawdown rate•
Ground Asorption Field(s)
a) no evidence of effluent reaching surface
or surface waters
b) surface water being effectively diverted
away from drainfield
c) diversion ditches, swales, rile drains aze
well maintained
d) soil cover, vegetation adequate and
mainta.ined as needed
e) protected from traffic and destructive uses
fl distribution devices in good condition,
working properly
g) repair area properly reserved, maintained
h) pressure head properly adjusted
YES NO Remarks
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Summary of Improvements and/or Repairs Needed:
Authorized Agent�,��_r��