A27 90� �
'1
Apalicatlon Date: � �a7 �I
Amount Paid• OU
Recel t 2
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APPLlCATION FOR SERVICES .
IF THE INFORMATION 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. �
11) Permit requested by: (Owner/agent/prospective owner):���Yna.S ��vG�t�
HomePhone:33�Co-3�Z.-Ll�J�{Z Address: l3yo Gr�ls� ST
BusinessPhone:'�3(0 -5G�-1�4�. '� boro �c- a�s�3
�
2) Narne and address of current owner.
3) Properly Description: Lot size: i0•O1 Township: Subdivision:�ol� �nc�"�' �afmrLot# I
Directions to the property (Including road names and numbers):
4) proposed Use a�n -�tructure Description: answer each of the following questions: � ��
a) Proposed _/, Existin Type of Structure: �-� ��� Width:� Depth:�_
b) Number of Bedrooms: � Number of occupants or people to be served: �_
c) Basement: Yes . N�r Wiil there be plumbing in the basement?
d) 6arbage Disposal: Yes , No�J � •
5) Water Supply Type: Privat�_ (new�+ or existing�, Public� Community� Spring _
Are any wells on adjoining property? Ye3�1 No _ If yes, please indicate approximate locatiori on the
'site plan. �• �-- � �'�--- ��,�aw Scs� �n �'ror�� ai� us
� p�� s �{,o �b�l-�,,, tt� � .
�6) Does your property contain previousiy identified jurisdictional wetlands? Yes_ No�
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMI7TED WITH.THIS APP�iCAT10N.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED. �,
➢ THE PROPOSED LOCATION OF ALL STRtJCTURES MUST BE STAI(ED OR FLAGGED.
➢ THE SITE MUST �E READILY ACCESSIBLE FOR AN EVALUATlON 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 shali
become invalid.
Owner r Legal Representative
a-��-�y
Date
PCHD, rev. U6I27/02
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T�x M�� ` F�.rcel # • �
s�U�b����.s��o�, � :
Pha�s�e-Section Lot #
Applicant: 1 �ts,`v�5 �cflvi �-C�, .
Permit Valid for � Five Years
Type of Facility: ��.
# of Occupants CiaK # o B �
Proposed Wastewater System: �Q
Proposed Repair: (�jc�L'✓t {i�cc�
Improvement Permit
No Ezpiration
New rl Addition Water Supply �_
� Prr»Pnt�d Daily Flow � g p d �
Type: c�'�`
Type: �G
�� � � c� �Z _G � �
Permit Conditions: GZ r-i-S �� �� 1�45�- ;� t,,lelfs.
Owner or Legal Represe
Authorized State Agent:
The issuance of this pezmit by the Health Department in does not guarantee the issuance of other peimits. 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 `Laws and
Rules for Sewage Treatment and Disposa! 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 attachments (�.
Proposed Wastewater System: ��l/�� �i%''l9c � l%�� ( Type �`' Wastewater Flow �.p.d.
New � Repair Expansion Soil LTAR: ��'7 S- g.p.d./ ft 2
Type of Facility: ��� 1�2� � Basement Yes D� No
Wastewater System Requirements
Tank Size: Septic Tank: D a� gal Pump Tank: gal Grease Trap: ga1
Drainfield: Total Area: ��.sq ft Total Length �� ft Maximum Trench IDepth `� in
Trench Width � ft Minimum Soil Cover: � in Minimum Trench Separation: �_ ft�� �•
Distribution:
Specifications:
�- Distribution Box � Seria1 Distribution Pressure Manifold
Authorized State Agent: ��
Permit Expirahon Date:
The type of system permitted is � Gonventional
the perinit.
Owner/I,egal
Date: �� �� �"
Innovative __ Alternative. I accept the specifications of
Date: �����
PCHD 1/17/2003
��s�� � ���
�r► �rrwRY .
Scale: � ' f/ � ��( i
PGHD, =ev. 09/12/Ol
2��
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` � � � ����
��rn�aa-�aamrn����.Il. ����.�.��n.
Applicant: � � �a.c.:�✓� � �"`
Location:
. d .
�. ': � �' �
=.�� �- � ._ � i �
/
T�x Map � _ P�rcel #
Subciivision �'� '
Phase Sect+ion��Lot #
# of Beda�ooms
System Type (In Accordance With Table Va): ��
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIAiVCE WITH APPLICABLE iVORTH
Ci4ROL1P�lA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHO Z TION. .
� ci�rv�-e� :�- �a-a �
Authorized State Agent Date
Date: �� ��� 5� �
('ts��'
�fi� 3a`�
��2� �o�l
c�q"('^ �
p_(j�1C Lvf ��qrk.t�v'
9►�'� � � '� `` ,,..-�'''"'
. ��1( c�s 7rKr' S��
1 � � � .�-O
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•r
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f �'�.- , `6 � � 1 a � �xi I �
� f� � , Q ca�' �g � ��,s�` ��j' � �r►,e.
a ,�� � ,� �r �nS
IrW^ r Io S
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PCHD, rev. 07/29/04
/J�j SEPTIC T�NK iNSPE��'1��! C�IECKLISi (Type II - IV)
Tax Map #—��� Parcel # 7c'� Sys�em Type (Tabi a)
Owner/Applicant Subdivision <<i ►-�
Address/Location Sec/Phase L #
Septic Tank nitia Date itr� �cat�on �nes n�t�a ate
State ID/date �e S� h S� Trench Width "� ft. 5�'
Ca aci � al. � � Trench De th l in. `�'
Tee and Fiiter T,rench Len th �� ft. '�
Baffle v� Trench Grade f
Sealant v, Trench S acin �
Riser if a licabie ��' � Rock De th and Quali
Tank Outlet Seal `^ Dams/Ste downs etc.
Permanent Marker � Pressure Laterals '—'
Pump Tank -- Hole Spacing "-'
tate ate o e ize ^'
Ca aci al. Pi e. Sleeve `
Wate roof /Sealant Turn-u s/Protectors �
Riser Required Setbacks
Water Ti ht From Wells t
Pump From Property lines S�/
Check Valve/Gate Valve Structures/Basements v'
Anti-si on o e itc es raina e a s �
Floats/Switches Surface Waters f
Alarm visable and audible Public Water Su lies �
Electrical Com onents � Vertical Cuts >2 ft. �
Rate m Water Lines ✓�
A roved Pum Model Vehicle Traffic ✓
Block Under Pum Ad'acent S stems t/�'
Pum Removal Ro e/Chain � Easements/Ri ht of Wa s
Distribution. System Other
Serial Distribution -� e Easements Recorded
ressure ani o ert� ie erator ontract
Low Pressure Pi e Tri-Partate A reement
A r. Pi e Material and Grade
Valves
Comments .
pchd rev. 3/13/01
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I� ��a4�r��n.��.���.�.]L IE'IL��.7L�7L�;
WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map /�
Applicant: _
Subdivision:
Location:
a1
Type of Water Supply: OL Individual _ Community _Public
Requirements:
Site Approved By: ,� Z 23 oi
Grouting Approved By: 23 0
Well Log: 5 Z 2� oS
Pump Tag: ,
Well Tag: 6/
Air Vent: �/'
Hose Bib: �/'
Casing Height:
Concrete Slab:
Well Driller: _��'v��'�
Well Approved by: � �
****See Attached Site Sketch****
Liner:
Installed by:
Depth set: _
Grouted:
Date: �
Water Sample:
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet &om any building foundation.
Other conditions:
Date: �' o� `� �
PCHD rev O1/27/04
Barnette Well Drilling Inc 336 598 9275 02/24/05 10:14A P.001
:� ���. � .. . �� : ��������� � D�GOOc� oD � 2 �l � �
.`� •�..- � . a o (�o ���.v�� cv�li
. �� �
':��D��7��� �,��,��,�,,f�
��-or�i.,rtqb.ua�t�.�ta��r��.mn: • 1�"��om�d�a lJ(�A913J L�JIfU�Ulal4! � zJ/a �J'~
1 �rout �,og
Ownex: �4S 1` ���FGOW�c'i Taa 1VIap��r7 Parcei #�
T.ocation: � c. . � K / Kr �
Subdi�ision: Lot # l � •
� ���.• ��.��-
Well Canstracti�n • � �
Distance From nearest 1'roperty Line (Minimum 10 feet) ��
17istancc &om Septic Syste�m (Mir►ixiuurn 60 #'eet) �U .
Tots�1 ]�epth: 7$� ft Yicld: � GPM • Static Water Levet; .� � ft
Water Bearing 7.ones: DepthZ G D ft ft ft ft '
Casing: - (�
Depth: �'rom (� _ __ to �v � f�. Diameter: �L�, in
Type: Gal�anized St eI ��
WGighk � a� Thioluless: �� T�eight above Ground: � in
Arive Shoe: � No Any problcros encountered whale setting casing? Xes (�i�
If "ycs" give reason•
Grout: '
Ncat: Sand/Ccmcut rr�Cvncrete GraveUCemen.t
�. Annular Space'VNidth inchcs Watcr in Annular pacc Yes No
Method of Grout: l'umped Pressurc Pourcd Dcpth to Ft.
Materials 'Used:
� No. Bags Poz�tland cement i �'/ � Weight of i Bag �� Pounds
If mixture (sand, gravel, cuttings) — R.atio to
ID plates: ��es _ No A x 4 slab Y s_ I�o
Lincr: . .,..
Depth: l]ate �stalled:
Drilliag Log
Gxaut• In.stalled by
Location Dr�wing
From To Forbaation �
< « �� `a�'
�' 4'x
� ��`s�'�rr
I hereby certify tha# tlae above informa�ion is correct and that this we11 was con.�bructed in accordanae wit1� regulatians set fotti�.
by the 1'erson County Hcalth U�pa�ment '
Sig��tvre o� Contractor
� rD # �� Datc
Pu�ap Installmeut
1'ump Iustallation Can�actor: �ifi� �r��.Gi State Registration Numbtr: 'z� y��'
pump Depth; �,� R Static Water Level: ,_� fl_ ft
�ump .MF►k.e & M��dcl'. ��,�,r�. )"' ,_,_. Pump Si7.e and Rating: �hp � gpm
Y hcrcby certs'fy that this pump was installed and thc well head completed accarding to thc Pcrson County Wcll Rutes in effect
on this d�tc and tbat a copy of this record been provided ta the well owner.
� . . Aate: �2� . � PCHD rev 4II27104
�ubop �nStallcr Si�n�turc „�