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A28 183Person County Health Department Sewage System Improvements Permit Date:21�-"� "I'his Permit Void After 5 Years d�� Owner: --�� G ���� ��� � /S� T �,rotinn/TlirPrfinnr �� ' - ' �, n'1 Subdivision Name: b �c Lot Size: .�� r� � C r'� �Type of I� Water Supply: Private: —�� Public: — Bedrooms: � Garbage Disposal _ Basement Basement Fixtures_ TNFnRMA'i�N �RTIFIED BY � REppIR;v`"- REEVALUATION: 1Z,� � 2- � � LOt # �_ Community: r i � , or rev entative ------------------------- Size of Septic Tank: i� U gallo� Size of Pump Tank: Nitrification Line: [��_�3 � Depth of Stone: 12 inches Max Depth of Trenches: Altemative System: Conv. Pump LPP P�mp Remarks: ------------------------- Date Well Approved: Well should be 100 f� from any sewer system By Sanitarian D Sewag ys Approved: 3--► G'1 '� BY � ' Sanitarian RTIFICATE O COMPLETION Contractor. �� �. _ _ ` _ � ------------------------ �, 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 hazazd. Septic tank and'�d nitrification 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 or intended use change this permit is subject to revocation. (G.S. 130 A-335F) L.ocadon of sewage disposal sewage system sketched on back. (OVER) ��-�-" ��� L��- �Y �v � , NOTE: Make sketch of installation 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 instailations may be located at later date: Note location af water supplies on adjacent lots. f (1) , (2) �s � ■■■��1��"i�����il�:�i� i���������■■ ■���l��l�����■�� ���������n■ ■�■ ;,�����������■ ■����������■ � ' Person County Health Department � WeII Permit � Date: -13-�1 This Permit Void After 3 Years �� '� Owner: '��Gk�/ �� Cla�/�I'c�N SR# r5-��,.-� Location/Directions: (,,�, A cvo s w, / S Subdivision Name: ' Lot # Drilling Contractor. C- WELL CONSTRUCTION ►� Distance from Nearest Property Line Distance from Source of P�' Pollution � Total Depth: FG Yield: ��GPM Stadc Water Level F� � Water Bearing Zones: DeQth _�Ft. F� f�FG Casing: Depth From Q__ to FG Diam�e�r' (QT Y Inches TYPE: Steel Galvanized SteeY If Steel, does owner a No PPn Weigh� Thiclrn Height Above Ground: Inches Drive Shce: Yes No Were Problems Encountered in Setting the Casing? Yes No ff "yes" give reason: '17 GrouG Type: Neat San ement � Concrete � Annular Space Width � Inches Water in Annular Space: Yes No Method: Pumped Press�g Poured� Depth From —� to G�FL Materials Used: No. Bags Portland Cement Weight of 1 bag lbs. ' If mixture (sand, gravel, cuttings) - Ratio: to ID Plates: Yes e/ No 4 x 4 slab Yes � No � � I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS COR CT AND THAT THIS WELL WAS CONSTRUCTED IN ORD C� WITH RE ULATIONS SET FORTH BY THE PERSON COUNTY H�}� D��ARTiQY�NT. V D� � !: Date Issued Sanitarians Signature Date Completed Sketch well location on reverse side. I r r• NOTE: Make sketch of installation 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. � H O � oa Amourit paid o2�• Receipt .4� � �10� �.:��g�'7 l �► -1 � - � `7 Date . -<.: 1 Permit requested by: . 7. Dimension�or Proposed Structure: owner/prospective owner/agent:�k�C(� L• C IG � idth: a _ � Address: _%�/ %�rc� �nY L h Depth: � � � a w �Home Phone #: � usiness Phone #: a z .5 �75Z/ 8. What type (if any, additions, expansions, or replacement is anticipated to the structure or facility that this sewage disposal system is intended to serve? Name and addre�s of current owner: 9. Water supply t}•pe: 'SG rr, P G S G bo JC� private �public ❑ community ❑ spring ❑ � Are any wells on adjoining property?Yes C�No �. � If so, identify location: . Property Description: Lot size: / �� . Tax Map#: Parcel#: 1 � Township: O 1�.V �.1�- i l` �. Directions to propercy: State Road #& Road James,�tc. /' ��� (.J �G�f /f �Pt � o Y� Number of occupants or people to be served: � . ype of structure/facility: Proposed: C�Existing: Q I Type of dwelling: �� House: C7 Mobile Home: L`� Business: ❑ ,Type of business: Number of Employees: Number of bedrooms: � _ Garbage Disposal? Yes ❑ No Q� Basement? Yes ❑ No f so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the Pet'SOn COunty Health Depal'tment for a site evaluation for the on-site sewage disposal system for the above described property. I agree that the con[ents 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 before an Improvements Permit can be issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of the site by the Health Dept., this application shall become void and all fees paid forfeited. / / Signcc� Owner or thorized Agent 8 Person County Health Department Existing Sewage System Report For: Hobile Ho��-b c�'�--t �dditio * Hame Phone# �� Kequestee: �rn�to l,�Qant�n L���C..��r;4a�, �( �� pnQ �p�c. L1�I . B u s in e s s n �UiJ� ����7��� 'Pa�c Hap� oSg"��� Location/Directions: � "`�Ji� ►'�i ��� `d` ���-'" ����?_. Original Permit Located , -1.� Septic System Uesiqned For: _ _ Kesidential v �iusiness Other (specify) # t3edrooms � # Employees Other Uate� rnstalled �--��-"I � Water supply �� I/ � V� �� Type of System ��Y �I �'1`iOn(`�,I 'IJTi�� �,U�"J� (�[P'�Or�l Hitrification Line �n3 I Tank Size 1 �`��C.�.�' Certified Operator Required � V /f'i On site wastewater disposal system sllowes no visually apparent malfunction on I I`V5"�' _ Yermission is granted to: _._1—f �'Yl� �-�-� � '� According to the at�ached site plan. Comments: ���1 �d� -I � ���� ������n %1'� i ;S ��-� c� �,� � n u� Environmental Health , '`�_::'�:._. . . ... . ...;;'=��':; _ DA ���ii�tiort Do-te: � � o�.� "U' :�aaaoanraa aaid' a � �i�e�r-�ot � �,3 a �- � CJ�-� �' � � � � � . - . • r�. srson� Caar�#v �?ea�th Denartment � . . .... . ..,,.. .;��nvir�m��ntai Healtft Ser�ion Tw: �l1ae� ,� � U 1`j�uc� T � �/ _ . =::, . . _. ._._ . -.. .. ..=.;. . . • . . ' `'s:. APgL"lCAT10N FaR SE�tVIC�3 • IF THE 1NFORMATION tN THE APPLICATION FOR AN iMPROVE�AAE3�T PEi�MR (3 FALS1FiED. Ct�lANG�i3. OR THE S1TE 1S ALTEi�Ei]. THE3N THE IMQROVE�IIE�IT PEi4M1T AND A11T'H�RlZATl�PI TO CaNSTRUCT SHALL BE�DME 1MVALID. 7) Permiireque�d hy. �wnedage�prospecfive ownerj: 2�cne 'el au �-� ►-, �Ga� 1�1�7�on� �dGv��►fcr ;n �ov� • Home Pl1o[te: - ' Address• _ �' n,� n Busirtesa Phone: ' � ��nX 6n m' 1� C'. �? 7 5 7 3 �- ..� - -, . .. 1 �Y L • ♦ � �• � . 3) Pra�eKy Des�ription: Lots�ze: �cTownstd� 1)1sY���: �� Dlrec�ons to the prope 4) Proposed Use and Structears Descr3�ltlon: answer eact� of the faltowfig questions: •� ai PropOsed 4 Exlsting� ' b) stidc ewt q�tarjsC stng�e w�e 4 aou�ie wtde a ct dd: }�` o n -lo `�a4 bf e(•��; d�' c) Num6er af Bedrooms:. 3e,c; s�i;�+r� P- ndd��(:of� Number of cccuparrts ar peapie to be seniec� � � �)...8ase�errt:Y�es•Q Na•�If�yes,#.ofbasementfpdures: . . .: . . _ . � ... �•_._ . . .. . . . : � � . � • ge, DiSpc,s� ^. •� j�,.�.- _. _�....,.: _ . _ . ...� .. . .,., ,. .. . � . . . -• :: . • . _. .:_ \ . .... , C'oark�a :'(es � �� I } ' gj Dimensicns af Proposed Struc�: Widttt: �, Depth: �, � e U I�00M b 0�+� Iro O N�� . �� -r---_ � 5� Wat�r Su�ply Type;. Private �4 (new � or ax3sting�, Pubi[c 0, Cammunity 4 Spring ❑ . •� Are acry we�ls on ac�oiniag propeKy? Yes ISi No D If yes� IacaHon � S} P�ease Indlc�t,e D�esired System Type: (sysiems can he raniced in order of your preferencaj . .• Canveraional _9AcdiHed CornreMionai � Attemativoe. I�novative o� {sp�r): CLF�IRLY STAKE ALL CORNEi�S ANO UNE3 OF iHE PROPEitTY, STAKE THE CaRldiERS OF ALL PROPOSED STRUCNRE�. Pl:FASE ATTACtI SURVEY PLAT OR SITE P�AN TO THl3 APP�ICATtON 1 hereby make ap�lication to the Pessai Caurtly Heaalthh Depariment inr a site e+ra(uation foc the an-si�e sewage disposal system far the above-de.saibed property. I agree that the carrterrts of this appiicatia� are ttue and �+epcesent' the maxirntun fia�afdfes to be piacad an the property. I understand if the siie is altered or the irrtended use ct�anges, tl�e permii shal! became im�eiid. l understand that as applica� I am responsihie for ider�ifying and mar�ing propefry Gnes, comers and maidng the siie ac�ss�ie fa' the personnei of the Persan Cawrty Health Departrnerrt to candud their evaivafians. I understand that I am respons�ie for natiiying the He epartrne� ii my ra erty caritains arry wetlands as designatesi by the Amry Corps af Ertgineers. � �� - � Da�-�� . Owner ar L Representative . Date � . � PctiQ, re+r. tan?1ss � M Person County Healtll Department Existing Sewage System Report For: ��Mobile Home Replacemettt Addition Requestee: 1�-�' / • ���f!%!� ��l �2(�( F01�' �N• �..�x (� ��0 1U .� 7.5 � 3 — l �o Home Phone# �,j�3� Business# ��757/ `Tax Map# / / g ' �O� Location/Uirections: iJ`�� �/�% �� k�-'v . �-r ui� �1,� st � sf-Fork - Original Perrait Located � Septic System Uesigned For: Kesidential ____�,� Business Other (specify) # E3edrooms � # Employees Other _ Uate lnstalled ���%9 9/ Water supply _ 'P yp e o t 5 y s t e m �_/T �Y%�J�i►1�"t..TY�QX Nitritication Line "�� � �3 � `Pank Size Certified Operator Required �/ V n On site wasL-ewater disposal system showes no visually apparent malfunction on � °�/11 � � % Yermission is granted to: ��GKV �1 ./�O� / According to the attached site plan. Comments: Environmental Health ��C.. /� TE F. WILSON WAGSTAFF 80-E-1�8 f'41'36"E 255.27' w � ;A 1 'Q N �� M �p � 1.00 ACRE 0 )W OR FORMERLY POINTER ROGERS IS . IF t CONTROL � CORNER I � � I � � L'S n�rr.c ��nliRwn�D" S83'41'36"E �277.92' A2 1.00 ACRE 298.86' N83'41'36��W RUSSELL CLAY, JR. D.B. 213, P. 489 ��� 6 �� � .5 �h� O� OJ� �GQ'