A28 196�•�ro�t�icn �ate: �-�31-D I
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� - . � rsrsoe� �auntv Health De�artment
. : ...: . � ' ;^;�nvir�nnr�ntai Health Section
, . .:;:. APgtlCAT10N FaR SE�tVIC�3
IF THE 1NFORMATfON IN THE APPt.1CAT10N FOR AN IMPROVEiNEiNT PERMIT IS FALSIF�ED, Ct�ANG£a, OR THE S1TE 1S
ALTEiiEi]. THEAI THE IMPliOVHNEN'T PEiiMIT APID AtJTHORIZATl�N TO CONSTRUCT SHA[1. BE�OME 1NVAl.1D.
i) Permilrequea6ed by. {Ownedagerrtlprospecttve ovmer�:Ss� _�_ �� � i?. 'TK � i/
•HomePhonaS03—OS'-SO � � Address: HS�S" hP.�r '� /�' 1,..
Business Phone: L/ 7 i- l��1� . . >2r� �' 6 n.� � �v. C 27 s'��
� Name and addres9 oi curner�t owner �lo /j %s w C' %�, �o �•
3) Property Description: t.,ot sizs: � I z�eTownship: o/, 'v �,l� %/
Directian� to the property (Includ'ing noad �names and numbers): _
�
I/ ��,
r'
��'
����s
� •
4) Proposed Use and Situcture �escription: answer each of the follawing questions:
a) Proposed �' Existir�g ❑ � .
bj SHdc Huilt Q Modular Q Single W(de ❑, Double WideY� • '
c) Numher of 8edraoms:. ;� • d) Number af acwpar�ts or people to be served:
� �). . .Bas�mer� : Y�es� q No� lf yes, # of basemerrt focbures: - . . : . .. . � . . . � � _ . _ - = - ..
� • 6ark�age, Dispc�ai: Yes � ; ��.:.- -, • _-,.....: � .. _ . ....,. .. . ..:, ,• ... . . .. r , �r . . ,. _...._ ' . .._ . _ .
� DMens�ons of Praposea stn,cttua: vVidcn:�deptl,: � .
5) Water Sultpiy Type;. Ptivate t�(new Sifoc existin9 �i� Pubfic O, Cammunity �. Spring ❑
. • Are anyl weils on adjaining prope� Yes � No � If yes, loca�an�1�is f
5) P�ease Indtcat� Desired System Type: (systems can be ranked in ot�der of your prefeiencs)
�Corfventional _BAcdifled Conver�tlonal � Altemattve. _innovative
Ctfia�' (�!f)� �
CO.El1RLY STAKE ALL CORNE3iS ANO LlNE3 OE ii�iE PRaPEi�TY,
STAKE THE CARNEiiS OF ALL PROPOSF.D STRUCTURES.
PLEASE ATTACti 8llRVEY PLAT OR S1TE Pl.AN TO THIS APPt1CATiON
1 hereby make appiicatian to the Person CouMy Health Departrnent for a site evaluation far the an-site sewage disposal system for
the a6ave-descxibed proQerty. I agree that the cartter�ts of this appiication are true and represerrt'the ma�dm�m �es to be
placad an the property. I understand if the siie is altered or the irttended use ct�anges, the permit shail become invaiid. l understand
that as applic�nt, ! am responsibie for ider�ifying and maridng properry lines, comeis and makir�g the siie �ssibie fc� the
persann of the Persan Courrty Health Department to canduct their evaivatlons. I understand that I am respcnsibie for notii5ring the
Healfh partrne� i my praperty c 'n a wetlands as designated hy the Army Carps af Ertgineers.
� �
Owner or Legal Representative . e�
PC3-10, rev.10/12199
Date: 1 � O
Owner:
Location/Directions:
PERSON COUNTY ENVIRONMEITTAL HEALTH
WELL LOG
�
SR#
Subdivision �Name: Lot #
Drilling Contractor: ����.m-�� ��� � 2-�-�� � nc
WELL CONSTRUCTION
Distance from Nearest Properry Line 1 v Distance from Source of
Po]lution ( G a
Total.Dep.th: �- F� Yield: L'� GPM Static Water Level a2.S� Ft.
Water Bearing Zones: Depth '�_Ft. ICi�� F� li �. Ft Ft.
Casing: Depch: From 6 to�Ft. Diameter: Inches
TYPE: Steel - Galvanized Steel .�
If Steel, does owner approve: Y�s No
� Weight: Thickness:� '� Height�Above Ground: /�/ Inches
Drive Shoe: Yes ✓ No .
Were Problems Encountered in Setting the Casing? Yes No �
Ir "yes" give r�ason:
Grout: Type: Neat Sand/Cement / Coricrete
Annular Space Width � Inches
Water in Annular Space: Yes No
_ ._ Me.thod: Pumped � - Pr:ssure � � Poured � - �
Depth: Fr�m O to � C� Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag__lbs.
If mixtuie (sand, gravel; cuttings) - Ratio: to
�ID Plates: Yes � No � � �
� 4 x 4 slab Yes i No
� DRILLING LOG �
Fram � To ( Formation Description
I HEREBY CERTIFY THAT THE ABOVE 1NFORMr�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C^v'vi�TY HEALTH DEPARTMENT.
0�.�,�� C � c� �_
i nature of Contractor Datc
Ta: j11aQ .::
�p��� � -v
Lar�tion:
�
New +V Addition
���d��3 ���i� a `.� �s'�����i��dlE��'�;L �?E.��.��
Tawnsi�i� P!N
Sui�division Pl�aselSe�toa LaiS
�t3'D93P�o1�[i'AE'�'3$: ��!'g91i�: �
.► ►
._ . � «� - ► �i e��
Water Suppty
# of Ocxuparnts�� of Sedrooms Other System Type
Projeded Daily Flow: � � g.R .�d. Permii Vaiid For. ive Years � No Expiration
Proposed W r Sy� em: l9�''
Proposed Repair �� �
Pertnit Conditions: ��P �il tC S���t
�wner or Legal
Auiharized StatE
Date•//�"Zg'° �
o�: %������ (
The issuance of this permit by the Health Department in no way guarar�tees the issuance af other permits. The permit hoider is
responsible for checlting with appropriate goveming bodies in meeting their requirements. ihis sibe is su6ject to revecation if
the site Plan, Plat, or the i�rtended use at�anges. The Improvemerrt Permit shatl not be affecbed by a cnange in ownership
of the sifie. This permii ts subject to campiiance vuith the provisi�ns of_ the Laws and Ruies for Sewage Treat�nertt and
Disposal Sys-�ems of the Mcrth Carolina Administrative Code.
Wastewater System Oescription: ��V � Wastewater Flow: _
Faa7iiy Descriptio�: 7 P i�.f {Ce�+ " idew 9�
Basement? O Ye's" AI Basemerrt Fcctures? Ci Yes �lo
Wastewaber Svstem Reauiremer�ts
Typ�
Repair � Expansion ❑
Tankage: Septic Tanic size_ �� � gal. Pump Tanlc sizs gai. Grease Trap size gaL
�� �d�' 'Trenches: Total tength U' " fit. Tr�nc� �dth 3 ft. Total Area 2 sq. ft. �
Max. Trench Depth: � in. Aggcegate Depth:� in. Soil Cover. � in. Trench Separation t ft. on cerrte�
Permit Expiration Date• -a'Z" �� ��� k��71�'L�(
Authorized State �Ager� �'t� � Date: � 0 - � ^� � "�-��� � "l �
�`See attact�ed site plan and addendum pages for additional permit canditiorts.
T3�e #ype af sysiem permitted @ does C8 does nat diffar fram the type specif+ed on fihe application. I acc�pt the
spec�cations � this permit. .
OwnedLegai Represerrtative SigtTature: ��� .„�_-�-%t pate; Jeh- 29-d l
�1J�Bf�lO(1 P@ftatit
System Type (n accordance uvith Table Va)
This sys6em has �en installed in compliat�ce with applicabie 1lorth Carolirta Geneta! S�s, Laws �td Ruies for 3ewage ireabmesrt
a�ed Disposai, attd all canditions of ihe Improvement Pennit and Canslruction Autl�ri�ation issuance ai 2his pe�mii im�lies no
guarantee that the systiem instailed wiil fiitu�ioa 4�vPeriY inr aml giv� perioci oi ticne.
Auihorized. State Agerrt. . Date
_ PCND, rev. 03/Q710�i
�ereby
oppeared
ue
�f ,
Centerline of a 60'
Access EaseMent
Ref,P,C, 9-86-4
Access to U.S, 158
is by this EaseMent �
To U,S, 158
N 18"24'14'W
91.30
N 03"09'07°E
12,15 —
N 03"09'07'E
57,90 —
e of a SO'
EaseMent
:. 10-51B �
I 28°17'21"E
43,43 —
u�� v c � ��t� i rv �,�i � i �vi � 4..v��� v��..�
�c-�:ober,2001 S�ale 1"=50'
50 �5 0- 50 100 150
SCALE IN FEET
Ernest B,Wood,Jr, PLS-2648
z5z N,Lar�ar St,,Ro�looro,N,C, 2757�
JaMes Dolian & Clara B.
Clayton
D,B, 275-837
N 87`39'03°E
_+25,12
o �
M
� 0-9 �r
�
_�
Q�v -
� N.�
� ^o
ti �
Z
a��� �
�
N 87"39'03�E
263,48 � �
� James Dol�an & ara , -
, 185,77 Clayton
N 86"52':z6'W
D.B, 275-837 `
, N .86'S2'26°W
/ �7.62 -
. , � . � •�1� / �� J•3ir ��� �� ' • •. ' .
• •�� •7 �
� . � • '.���,���
. . . _ _ ._ ... . . . . . . . �r-i��a��'R1111'R'11 ��1��.� ll. 1���� �
.—___.._;�,���#: � �� . : Parce� #: l7 �
Zcning: Township: ' �
S�bdi�ision: � ��r:.: �:_ � ��� . Section: Lot:
Applicairt:
- �� �f � Locaticn• � � � �
� � eration Permit
�;:
� •�
e
. System Type (in Accordance With Table Va): �a
THIS SYSTEM HAS BEEN INSTALLED IN COMPUANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVENIENT PERMIT AND CONSTRUCTION
AUTHO ON. -
� � . la- l�.�o �
u orized Stat gent Date
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T��� � 2�' � �� l�� . �
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Zonin9 Tow�hiP
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subdtvhio�
$�� �
. Well Permit ��
� T��e of �iVater Sua�iv: Individuat Communiiy Public
Reauiremeni�-�
S'�e Approved by
Grouting APProved by h� . �--����
Well Log i /� �3"d
We!! Ta �
Air Vent
Hose B�
Concxete Siab
. ('J 5'
�2
� fi��
Weli Drillec: � �-�.���. � ��� � ��
� � � Daie: 1 � �� -o Z
We11 Approved By: .
� . . .�. . . . ' �. .. .
� �*S�e �►ttac�ed Site Skefic9�'`*
Well� must be 'f 0 feet from property lines.
1�yelts must be 100 feet from septic systems-
Wells must be �at least 25 feet from any buiiding foundation.
Other conditions:
PCND, rev.11/29/99
0