A28 17Appiication Date:
�f �23-� �
Amount Paid: 1 a2. .�—
Receipt #: �1 ?G 2 �
Person Countv Health Department
Environmentai Health Section
APPLICATION FOR SERVICES
Tax Map #:
w--�
Parcel #:
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED CHANGED OR THE SITE IS
1) Permit requested by: (Ownerlagent/prospective owner): �<_.t'rt�0 ✓� ��
Home Phane�33�) 3a.�- ��.C►s Address: � Lc�s
Business Phone: � 3c•) S�y -y9��i �o C.
CG'u-�# �_ n /�
2) Name and address of current owner: c�So /� IC ��'S ��'� S
� � L�.,s ��
� bo�o , N C. �7 S� 3
3) Property Description: Lot size: I•atic. Township: O�%� Q/-l%/1
Directions to the property (Including road names andn numCbers):
Ll'c�5���1 'Lt��C/''' nC � J M
--� ,_ ,. ._ . _ .
,t1��S
.c c;-�Y �•,�.;+s
Q. !20'7
4) Proposed Use and Structure Description: answer each of the following questions:
a) Proposed ❑, Existing [�'
b) Stick Built C�Modular �, Single Wide ❑, Double Wide 0
c) Number of Bedrooms: � d) Number of occupants or people to be served: 02 .
e) Basement: Yes e; No � If yes, # of basement fixtures:� �
fl Garb3ge Di�posal: Yes 0, No B� __ .. _._ .
g) Dimensions of Proposed Structure: Width: Depth:
�.e `�" �
�����
5) Water Supply Type: Private �(new 0 or existing ❑), Public 0, Community ❑, Spring � ,�.I
Are anywells on adjoining property? Yes C�No ❑ Ifyes, loqtionc��i„cw.�Y ��top e•1� o'� yn��- �o��l
oZrc� t�f�••c c-�c� `/
6) Please Indicate Desired System Type: (systems can be ranked in order of your preference)
�Conventional _Modified Conventional _ Alternative _Innovative
Other (specify):
CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION
1 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 invalid. I understand
that as applicant, I am responsible for identifying and marking property lines, comers and making the site accessible for the
personnel of the Person County Health Department to conduct their e�aluations. I understand that I am responsible for notifying the
Hea Department if my property contains any wettands as designated by the Army Corps of Engineers.
�� � y-o�3- oa
Owner L al Representative Date
PCHD, rev. 10/12/99
���; f �lle�� �� ,
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7Eaa�asoaaaasosa�al 7H[ ae.�.�Ila
SITE SKETCH
N ��-Son (3r-t ��f TaxMap # �d� Patcel # �1
S vis'o �n- _ Section/Lot# N/A
C� a t� -� a
Authorized State Agent Date
Syatem rnmposenta represe�t approximate contours only. The conimctor must flag the syatem firior to
beginning the iristallatioH to i�sure thatpropergmde is mai�tained
— — �1 � � l� —
Leasburg Rd, .
U,S, 158 <60'ROW) S 8 359
S 86'29'05'E
177,77 ,
� �� �
`j� P��
Hedgepeth Farr�s
of Person •co,
D.B, 131-270
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PhllUp C,Morrow
D,B, 196-124
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�E7 �_, FIANGER ___--�---
irson County Register of Deeds on
day of �--- M ' �9"_�
o'clock
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D,B, 196-'
�Line Shown For Clarity
Ref. D.B. 127-449
D.B. 127-450
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i Ph�lUp C,Morrow ( � (�
D,B, 196-124 r�M ��C��� ►�
S�°`� � s� �
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. �' • ,u a-_..vaora.u.:�*�.u;,.,�...-ua.—s��sL::ne
!. 6arrett, Regfeter of Deeds �.
��3zS0(d C�l��l�'`l Ei�IV113�NME�i'd"AL NEALTH
PLF�SiE S�� P►��C1�E� �L��l Ft3R WEi.L Si'TE LA'1(�19�
T����a� � _ ��� � `r
ZoNng Townshtp V � 1V t- �( � �
„�pu�,,,� �u�5� ^ � r" � ��j �� s -�.
�n � 5� l,� ��f33�x #� 3(o a I ac.r-o s s�ra.-r,
� 7��, W►��st��.� R-d�
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Subdiviston: � i � Section:
Tvpe of Water SuapiY:
Reauirements•
Weli Permit
� Individual Community Public
Site Approved by ,/3 � 'I - 8'°a
Grouting Approved by�5 7-3-��
Well Log c�s �- a-dz
Well Tag ✓ ��r ��8-oa
Air Vent ,�,/ � � �-8 "�
Hose Bib �i� 7 8-0,�
Concrete Slab
� �5.�,���.�.-x �.'
(,�:�+r.ass-cL
�:,,� ,��.�.� �1 ���- �� � - 3�-z..
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�\ 1���� a�'���� � .�
�11 -a-b� �,,., � �,�., �-� Z ��- �.�
�2 �r A�� �� �QA\ �., z - 4�-��,
Well Driller• ��-►+� �� � �� � �• �
Weli Approved By: � Date•
'1 �$-o Z a�
eb e�d 1,�,:t.�� w�� . ��. .
**See Attached Site Sketch'"'" ��
�J�7�� �n5-Ectl�� C�Si+��, d�(� 5' bc./oc� 1����cr �t� �n old G� 11
.�o hciP insu,�c r�cali��, Pr�blcm W�tir vc�'r, Dut, .
Wells must be 10 feet from property lines.
Vyelis must be 100 feet from septic systems.
Welis must be �at least 25 feet from any building foundation.
Other conditions:
-� �,ban
don c���l W/ L iner P�mQ oL�-t, Ch IOr�nG'�C � F,��I w/cem��-t.
`�r� U �t3wy, Qump 0�,�--�j C� lor in c�t c�
— (�econ►mcn� aban�an�+� tat,l! �'� ' F,�i��-F��c� Ce�ncn-� �ap.
r� �0 W � �' h J O
Ce �yl Gil'�- � i- r 1�� ��� L' <<a �� � t ci C I G+-y PCHD, rev.11/29/99
!
Ju1-09-02 08=00A
�r�
. . ._ . • • No�th CarOlit� • •:�
Depar�cnt of ErnrtroammE ar�d Nr�ttuiat R�sources
Dtvt�on oi watar gu�ti�Y
Groundv�ater Section
P.a. 8nx 2957$ - Ratei�h. N.C. 2?828-0578
_..., - - n �-- � � _
1.
w�i.L iACA?ION: (Sh a a! the locaRsoa on b+�1t o` forra.�1 ���5
Nease�t Towrt:_�Q� � - - ���.� Caiaty
��
�lnad. Caaamunit]r: bdlvlaiou. Lve Ko.l
P.02
Z. OwYER: J c�svv` �2c wEu. otACT�RAbt: or�ar a derauect eketch of. -
-�— — tbe �rdt yhoaia� lotal depth. clepth aud dt�
3. ADDRE:S: . eoeter o[ �ereeas re�int� ta the rv�dl. gcavel
�ues�al, iAeeraals ot casia� pasfaradans, and
4. iUP4Gti!►PHY : �ra�w. �lope. hllitop. valley.�a
depths arui type� of Qil �.�erial3 usa.'.
S. LISE OF WE3.L: J%�`QJ-�i � DA'LE: �
8. TO'L�1. D$PTH: ��TDIAM�`!'Ei� � `r.--�---
7. c;.�S[NG i2�11�tOVED.
�. �tC�
C?C ( ��
8. SE�U.INC M�1gi�L:
N����nf� �
`ail,jj9 Of CC�S1C11C �+ �i�i O= ClQiGA- �„
gal�. uf wace.r yd�• of aaad r� .
�, qt' a►atet� ��
�Z
Typt rnataial
�ourat
9. �PLAf, t ML I'HC�D El�1PL1CSMEIVT OF MA7ERSAI..
�
LJ
I do bKsebr certlty tlsat this w+ell ahandonmer►t record Is true a�d ex�o�ct.
• , �
Si�nature e�! Cctstratbx or A�ent � n�tte
W�LL LOCAZI�N: Draw � laratt+��i ak � on tlie re+rerae Ct ttst� eet. ybowi�',�L eLe diret•
e3an auxd dutaaca tha we11 m st !wat cwo lz1 ae�rby rd'� pa41a
suCh ae roi,da.lnteraeeU�a aAd an�s. idel7ril�r ratrcls vith StatC Higl�
way r�d ulmt!!lcanon nkmber�.
Submit ongt�zal to tLc ,Divt�lon ot Wat�er' Au�11ry, oQe copy to the D�illes.
a;pd oqe copy to 'tse owner.
GW-3Q Revt�ed 1l96
I
�, i
Ju1-09-02 08:OOA
'.'�---.
. : -- . • Nort� Ca�1�'� _ '
Depu�a�r�t oi Envlroasment and N�turial� Rr�iu�ces
Dtviedon of i�'attt 9�xY
Ground�ttcr 5ect�a
P.q. �o�x Zg578 - galeigh, N.C. Z7�26-0378
1.
ACTOR � � c � ��r.s��. �.,�. ...,.
L �OCAT(ON: (9t���� aE the lo�ta� c4 bar�c of tarm.)
Nca�rs�eTa�n:,__ K�' C,aincY
ainad. ContmualtT• Sybdtviaioti. Irut No,) --
2. OwYi ER
3. ano�s:
4. 70POGxiAPHY : �:raw. �lopc, htlltqp. v�ileY. �Y
�. US� dF v�tELL:.:��.�5�.-�-�T�' � �
6. 'I`OTAL. DSP'CH.�� Dtw�AE'TEIi: - �?
7. C�151NC R�iOvLD.
� ��
8. Sfi.tL:NCi MA'TEi�l1i.:
�Ys�r.sCa�L �
5aga ot ceater�t �_ baQy of cemen: �_
�als. 01 aarrr �,._ ycl�. of �.yd
-d�.�
�, q j aater �vc� -
�st
�rype d+�cene�
,�mount
9. E?�[�iY D+I�.`37riOD EMPI.�� O� 1�tA'IERiAL.
,,.
P.03
qu�,dra�a�►s o.
.L DU►C)RAM: Drzw a d��iled eketch af
�neil sha+rin� toeal depeh. dapch aad dia-
x ct scre�eas rem;lAlag ln the wr.11, q,ravd
cval. ir�LesvAls of csair�g pa�faraaons. ac�d
Ch.s and types of � maxrsals wec'.
`5
i�
I do h�ateby �lty tlsat t�ts wdl ab�d°�me�t rc�vcd Is �ue aad ex�ct.
. Sigtueure of Caaa�et4r a Ageut �� �� � Date � � � - �'Z .—...-
V�/c,I.L LOCA7fON: Orav► a Io�atsoa sket�h an the t'�e�v�e of tisis aheet. ahowir,g �e dlrec•
ttan aad distaae�e of t�e arell to at :east tw�o t� aesrby ref� potiats
�uch a+� cvad9. iat��ctlo�ss and �veams. ldtatiljr t�ads atth State Hlgk�
e.�y ro�s�d ldeatiIIcad,oa numbres.
Subm�t arig�al !o the DhAslon otWat+er �uallty. oae copy ta the D�71ier.
and oae copy to t�e owner.
GW-3o Ra�vmaed ! /98
���,5� ���� �� D�[[lor� �D � .�
� ������ �� � e.
I��.�.a-�������.� �[�.�.Il�� D�o Dr��ca�l 7 2-��_
Well Log
Owner: _�,�n,., �j,,�i��� Tax Map � Parcel # ��
Location:
Subdivision: Lot #
Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from Septic System (Minimum 60 feet)
Total Depth: �_ ft Yield: GPM Static Water Level: �� ft
Water Bearing Zones: Depth - ,. � ft ft ft
Casing:
,
Depth: From � to c'1' � ft. Diameter: / in
Type: Galvanized Ste�el i/ rCj
Weight: Tliickness: •%g� Height above Grouncl: J� in
Drive Shoe: _�� Yes No Any problems encountered while setting casing? Yes �/No
If "yes" give reason:
Grout:
Neat: Sand/Cement
Annular Space Width
Method of Grout: Pumped _
Concrete GraveUCement
inches Water in Annular Space _
Pressure Poured _L� Depth
Materials Used:
No. Bags Portland cement /� Weight of 1 Bag �/ Pounds
If mixture (sand, gravel, cuttings) — Ratio Z to /
ID plates: �Yes � No 4 x 4 slab _ Yes ✓No
�
Yes No
to
Drilling.Log Location Drawing
F�
From To Formation
� - l
��/ � .�s��
, h�
�0(� r'c �ac1i
�� �,``��; ���
1��
. �o u �of�
I hereby certify that the above information is corre and that this well was constructed in accordance with regulations
set forth by the Person County Health Dep e
Signature of Contractor �� ID# �-�Q2-�1 Date
PCHD rev Ol/16/02