A29 112Amount paid Q,V�
Receipt l� '������^�
C.� 1 1 ���
��� ��� —�
Date
~`` �`" `�" ``� �.A-"` '-- ; , r--�r ���'Sefvi'c`esiR�e(7u..."'-e..sf ed`� �;.'' �� :.Y "' �s ", �`-�,�t°'
:"''%+-� .a, .�,._._ .i:_ „-Oes'3.�.'..'^�- n. s::.... ,�2.�. _ ':..�. .s..t...�.r�'.%i:Y-.'i's�
Impcovements PerraiG ("rstab[ished/Recorded L,oc) .I_ Reinspeccion oc �xisting System (Loan Ciosing)
Ime,:cvemencs Pernit (Unrecorded Lot) I_ Re�airl?Zeplace existing Septic System
jmorovemeats Perr.iit (Mooile Home Replace) �_ Pe;znic for New Weil
Improvements Perrnit (Addition) ,_. Replace Existin� �Well
;W� . , �� w�� 'fi —an�-..,.� � f:: ,;� �..-�tL9r ' .7nr� �..Z. -'«.iv� _ �.. .� 'rX �
�«�Wafer�Sam Ie�to=b�e:CollecEed ���.-
`_�`t-.�..' �.��'_t.�,.rl.,•,�i..W_.,. _�^ _ '"..- :L.r,.
_ B actecia ~ I _ Chemical _ Petroleum �I �_?esticide
1. Pecr:�;c reques:ed by: .
�wne:/prospective owne:.'a
Address: - � i.� <<
;
�
v Home Phone �:
� �- 59 � -� C�7 �
¢ usiness Phone �. �
a.
7. Dimensions or P:oaosed Scructure:
Width:
Deo[h:
,_ Lead
8. Wnat ty�e (if any, additions, expansions, or
replaceme�t is anticipated to the structure or facility
that this se�vage disuosal system is in[eaded [o serve?
Name and address oc,c:�rrent owner. 9. Water suopiy t5•pe:
' private �. pubtic Q community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No �.
u so, identiiy location:
3. Pro
: Lo[ size:
Tax Maprr: . .d-t �`-'� �
Parcel�: � -Pjq
Townshio• � b�C _ �{�
Directions to propercy: Scate Road #& Road
ames � ' -
.
Number of occupants or people to be setved:
10. Type of structurelfacility: Proposed: DExisting: C
Type of dwelling:
House: ❑ Mobile Hame: Q Business: ❑
Type of business:
Number of Employees:
I�Iumber of bedrooms: ________ �
Garbage Disposal? Yes ❑ No Q
Basement? Yes 0 No� If so, n of basement fixtures
CLEARLY STAI� ALL CORNERS OF THE PROPERTY AI�ID THE CORNERS OF ALL
PROPOSED STRUCTURES•
I hereby make appIication to the PerSon COunty He3lth Department for a site evaluation for the on-sit:
sewage disposal system for [he above described property. I agree that the con�ents of this application are true
and represent the maximum faciiities to be pIaced on the property. I understand if the sice is� al[ered or tiie
intended use changes, the germit shall become invaIid. I unders[and that before an Improvements Pecmit can b
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
deIivered a survey pla[ of the propercy to the Health Dept. within 60 DAYS after the date of the evaluation of
the si[e by the Health DeoG, this appiication shall become void and all fees paid forfeited.
�- z ' Signec� Owcy�r or Authorized Agent
:�• �� ,�.
-�.____ _ .. - � - - - - - --- -- --� _
FROM :PERS�I C�LRJTY COURT ST GOU COM FAX N0. :336 597 1799 Jul. 31 2002 09:02AM P1
. �� ,�.p� � �i
���� a .� � v ��
'� � 3 -6 s����__�.,_.
� �
� � p'� P� I I
-�.�`�—�.`� .S�` �I�Ik�� �1�
�-�- - � � � � ��-a-�
�F3'ram�`�.�^3a�awca---- ..�mdsa.7l. 7E—��-r.�r�.]LeE�ka.
�.:1•. ��: :i :iI�T-:
1) P�rtnit rsquest�d : Owna � �1 �U1 `�
Home Phone: � �p �pj'DSp�va owner).
� � Address• '
Business Phone: A a
2) Name and addrsss of curnent ownar. "��i.� �JrL��
3) Pmpo�rty peectiptfon: l.ot size: �°/ Tow�ishtp: �1% G ltt� Subdlvision: �'Jle �� �C.�ot #�
Directions to the prope.xty (I�►cluding raad na�a and num��; • ,_
�SLPr li n�i�in.,, flil ..�K ,P'Y► � /`S r e .
a} aroposed us� a„a structure �Scr��on: answer each af the fdlowing questions: �
a) Proposed �,, Fxisttny , Type of Structute; 1Mdth: � Depthu,�,___.._
b) Numhet df �edrooms: ,� Number of occupants or people to be served: _,J,_ �
c) 8�s�ameM: Yes,,;,,_, No ✓ Wifl there be ptumbing in the basement�
d) Oarbage Dl�posal: Yes �,, No ✓
5) Water Supply 7ype: Private �(new o� axis�ng�J, Puh�ic . Community;,_,_,, SpNng _
Are any w�lis on ad,joining propert�t Y�s Na 1�If yas, pfease indicate approximate IocaC�ari on �Il�ic:�
�site pta�.
8} Qosa your property contai�,pre�lousiy identtfiocl)uHsdlclionai wetlands? Yes_ No �
PtEASE NO'1'L_'i'� EOi.LOWlNG:
9 A PLAT OF THE PROp�RTY OR 3iTE PLAN MUST BE SUBMtTTED WITH THIS AP�'�.ICATION.
➢ PROPERTY LlNE9 qND CORNER9 MUST B� CI.F�4RLY MAR1�D. .
� TH� PIR�POSED LOCATION OF ALL 9TRUC7URE3 MU3T BE STAKED OR FLAGGED.
� TH� SI� �IuBT 6� RFJIDILY ACC�SSiBLE FOR AN ENAI.UATION BY THE HEALTH DEPARTME:MT
3TAfR.
I hereby make application tn the Person County Health Dspartment for a site eva{uatton for the on-site aewaa,�e disp��sal
system tor ihe above-desccibad propeKy. I agree that the conte�ts of this ap¢Ikation are true and represent thc� maxin��um
facilitle.s to be piaced on the prope�ty. I underatend if the site is aiteted or the intended uee cha�ges, the ��ermii :��hall
i�ecortte invalid.
., Z/—o z�
Date
acHn, ►oY. n��;z7roa
�1�.' j�.) � ���� ��
�__._� `"'— � � � � � �
I��n�aa-��n�•-„-�„ ��a��.71 IF���ta.Il�I�n.
Applicant:
T��x M�� , / P�rcel #
S�u�hcilivis�ion �� � � �.:
.
Ph�s�e Sect�ion Lot # •.
Improvement Permit
Permit Valid for _ Five Years _ No Ezpiration
Type of Facility:
# of Occupants # of Bedrooms
Proposed Wastewater System:
Proposed Repair:
Pernut Conditions:
Owner or Legal Representative
Authorized State Agent:
New Addition
Projected Daily Flow
Water Supply �
g.p.d.
Type:
Type:
Date: I d a3-4 �
Date:
The issuance of this permit by the Health Department in does not guarazt the issuance of other permits. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and oning 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 Disposal 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 �yastewater System: � �r0�T�0 Type �_ Wastewater Flow �g.p.d.
New �� Repair Exp on Soil LTAR: .� g.p.d./ ft 2
Type of Facility: �j(� S�� Basement _ Yes �o .
Wastewater System Requirements
Tank Size: 5eptic Tank: �� gal Pump Tank: � gal Grease Trap: �_ gal
Drainfield: Total Area: �_ sq ft Total Length �� ft Maximum Trench Depth a�_ in
Trench Width � ft Minimum Soil Cover: �2 in Minimum Trench Separation: �_ ft
Distribution: Distribution Box LB�erial Distribution Pressure Manifold
Specifications• � �
Authorized State Agent: � �.v Date: ��'�'��
Permit Expirahon Date: �— I�1- p l.�
The type of system permitted is ✓Conventional
the permit.
Owner/Legal Representative• ,fi
Altemative. I accept the specifications of
Date: � 0 'a3 - 0 �
PCHD8/28/2002
1.309 AC
22
___.__ 2 32
' 24
�
�� 1.608 AC.
__ N3°35'2�1��
77. 21 '•
j 25
►
� 1.609 AC.
�
� a77.2�' CJ
N 3°35 29 --
��
� ,�j �8 '
� � I.SIS AC.
T .��
� �'��� IRON FOUNp �T
��
' i ARCH C. �pHNsnN
�
iM
o ��N �
�
62 AC. ;
�
�
� ' 29" ��
,
. �
Z
\
� �� �
o -�
7 AC N
�2 ��W �
O'
. <o,
�1.676 I.
�cl �I-
�
ti
��'p'�!' `�► �g�
3� •
v ���� � F
ro �
� 6 �,C ;
�` .230 AC.
��
� ,�
�s � y`
�. ;
,��,� , � �
cs� � / ,
� / �
. ��
� i�
/
� ,
�
.i
���� �� ���� ��
� * �� ������
I�����mm � ��.¢�.11 I�3L��,.71�1l�.
Applican
Location
T�x M��p ; � P�rcMel #
S�ubcilivis�ian • , � �
Ph�s�e'S�c�t�io���=Lot �
�peration Perrnit
� � System Type (In Accordance With'Tabie Va): .
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLlNA GEIdER�4L STATUTES, RULES FOR SEWAGE.TREATMENT AND DISPOSAL,
AND ALL CONDITIONS ,.OF THE IMPROVEMENT PERMIT AND. CONSTRUCTION
�A►UTHORIZATION.
._ Z / �v- d � : . . .
Autho ' ed Agent ' Date
Installecf By: i5 � Date:� 6 3 �
j�TS �oo 0
. - -
. . . ��. _��z._. . ._.._
� � �,� ,; � ,,
� S�o
�� —
,,
S�� ��z r-,�—�� n.
��g Ln/ �i.—
PCHD, rev. 07/29/�2
S�3��'�G i�►�9� 9R9S�'��T1�N ��9E�8�L�iS�' (�y�e 11- I�
Ta: Map #� Parce! # �/ Z System Type (Table Va) ��
Owner/Appiican# Subdivision �
Address/Location Sec/Phase Lo# #
. _�
I V
Septic Tank n� a ate �tn cat�on ines n�iaa ate
State IDldate �5 ��"� � z
r� Trench Width ft.
Capaciiy. /aoo . gai. ✓ Trench. Depth in. ��
Tee and Filter . ✓ Trench Length ft.
Baffle Trench Grade
Sealant � Trench Spacing •
Riser iF applicable) Rock Deptt� and Quality
Tank Outfet.Seal Dams/Ste downs etc.
Permaner►t Marker � Pressure Laterals
Pump Tank ,� Hole Spacing
tate ate � o e �ze �
Capac'rty gal. � Pipe Sieeve �
Waterproof /Sealant Tum-upslProtectors
Riser � i�equir�d Setbacics .
Water Tight From Wells �:
Purnp From Property lines
_ Gheck ValvelGate Valve : Structures/Basements
Ant�-siphon o e - �� rtches rainage ays
Fioats/Switches �� � � .... . .. _ . _ . - Surfa�ce`Waters
Atarm visable and audible Public Water Supplies
Electrical Components Vertical Cuts >2 ft.
Rate (gpm Water Lines
Approved Pump Model Vehicle Traffic
Blocic Under Pump Adjacerrt�Systems �
Pump Removal Rope/Chain Easements/Ri ht of Ways .
Distribution System Other
Serial Distribution ' Easements Recorded .
ressure an o d e' e perator ontract
Low Pressure Pipe • Tri-Partaie Agreement
Appr. Pipe Materiai and Grade �
Valves �
Comments� �
pct�d rev. 3/13/01
03/19/2003 11:20 336-388-5940
�� S -� � .�-� � �"� � �.-�.�' CC_.���y/�
`�r+ 1 n M � .y� +/- � +� �}rt �</
� ��e `11 1 � II 11"
,+, �.% ``% iA r�n.
� - ^ -��r .�..,n.Jtu:lir.
1St'7\�71 A � ]LA7l'7�-'i�-�Cs k71. �L'r:�t �L �JA. .1L
r
amer:
?catzon:
ib@ivisidn:
' EVANS WE�L DRILLING PAGE
st'' ' ��ft%�fl �l ° �� � �
� ����in�" .�v ��„ ��e. I � r► i �, n�S
� D�Q� . 3 /. a�
��� �Ob
'1 ��: i�Ea�� �� P;ucel f� �%
4 � c T t i K`'f. - -
�►,.
_ Lot fE �_
Wcll C:c�usCc•ucizo��
;st�ncc rz'om t�c:ucs[ 1'r�pc:i�y Liiic: (N(iz�imum 1Q �t�et} �`� ,�___„_.......
:stancc �om Sc:�tic System (Nli��imum GO xc�:) `�
�tal I7cpth:l(a �.-- f� Yield: �� -,,,,^ GPM Su►tic W:�t4r L�v41: _� [l
'ater B�arinb �onGs: Dcpth�lc �. -- tt � it _ tt � it
asua�: .
�ch:.�F.rom r� --- lo �� il. Diar�xctc:r: � ill
�pe: Galva4ized Stcc! �
Wezght: , 13 ---'�'k�ickn�ss_ 1 t� s'_ fle:ibl�.?' abovc GCo«nc!: _,�,�� ij�
'ivc ShOc_ f Ycs No Fl,ily pfUVl�►�tls 4nc�u:�lcrccl Wl�ilc: ��lL1Ab C:1�i13�;� __X�s �NO
��CS'� $1YC rC�S011' ' "'
rout: �
Ne�t: ,� Sand/Ce�nc��t •f' Concrctc G.av�l/Ccit�.cc�t _._—
A.n,nular Spacc Widtl�; �--^ iilct��s Watcr in A,�►uu1�u S acc Xe:s `� No
Mctl�ad of Gcout: Pumpcd ��rc:ssurc ` 1'oure:d __ Dcpl17, �� td rt-
�
:atcrials Uscd:
No. B�gs Portl�a�,d ccmcnt _ Wciyt:t ai' 1 13a� ,._ ['�u��ds
Ix rziixLtuc {saizd, �r�vcl, cuteinby) — �atio _� �� ��
XD �latea• �'cs � N� �F :c � s�ab �ca �,,., N�
uxilliub LoJ; __y^^_ _ �'°c:l(i�n 1J�'awinb
�+'rom To 1�url�i:iL•ioi.
w��
� L �J •
y 1 a � �'�•
_ �
��–�— -•
01
hereby ecrtify that ttie �bovc'ti�,£ortX�ation is co:rect �uld tl�ai this wcll was coizstruc�cu in :�ccordancc with z'e�ulatio�s
cc forth �y ch� Pcrson cou.l..y klcaltlx cpartari�nt.
�i aturc of Coutractor �C'� __ i�)1� �o� �:ttc
s� PCI�D rcv 011ld102
��
�
�, , �
'�..+►� � y � � � �L.J ��, �7 � �
�7m,�It'I['aCD7rL.aDC71a�'�'Il.�.�.Jl J.L JL�.�U.111�.3CIl.
Building Additions/ Mobile Home Replacements
Tax Map #:� Parcel#: // �i
Approval Requested for: Mobile Home Replacement
_� Building Addition
� /�
Applicant Name: � h� �v� �� Y
Address: 02�0� L <S
v�,'(J�� /�lL o2 � ��
Phone#'s: �l��l �'3�l'�Ss`lr� 33G�s��-7S~� 1
Permit Located: Yes No
Installation Date: ��i o� Design flow: �� (gpd)
Current Contract with Certified Operator on file (if required):
Water �upply: � � Well Public or Community �
� Wastewater"system shows no visual evidence of failure on: 3��, G� (date)
(Applicant's signature if site visit is not required)
' j Addition/Replacement Approved
Environmental eal ecialist
11/15/OS
� ��
D e
�
. i
. /
.. /
/
/
/
/
IF � /
----�1
���
z
0
t,� w
w �,
�
N �
� O
�
����(�''��°�(
����,, ��.,?-�-•'''�T
�''���.. ��
o p�c�� ���.� ��
LOT 8
"ROSEVILLE RIDGE SUBDIVISION"
_ � 0�8
2>p �7„
�a, �
��� -��.
p���;J�;�c, ��.
� . �� �CI�S��
�or 2
"ROSEVILLE RIDGE SUBDIVISIO�!"
P.C. 4„P. 118
89.8'
228.00'
S86°24'31"w
_;
,
�
,
,
,
;,
i
i
i
IF
CONTROL
CORNER
�D � t`—'L'O �/
3�z�`o� w
. V � W
o cn
O N
O c0
IF
"ROSEVIL�
i � IF
TO
SR
�1�2 �o' R�w
___ - �
_ ____- -
_ ____- -
_ ___-- -
-- d
__ _ - -- - � 1 �1
_ __-- -
_______-------- _
03/19/2003 11:16 336-388-5940 EVA�S WELL DRILLING PAGE 01
`'—�� S .��.—'.�.:��l.�.e� ��� ���uiuii�cr aU w- ..�....�-y-J
`~�--� �„� � ��y- �- 4 J i�}u.'�� � � l �,-n S
�—�--�—` C� c� �� .��'�� �n1, 1�(li���i � 3 �� 0`3
� [' r 1��Lu�n. lJ� lJ��'J�+ r
�2Z'n'C✓7lA •Cp3�71'Jl'T-P..C✓1A,T.II'..�ILII. �,l�.l�Cs.:l+. ,.
��� �Ob
�' "1's.� M;tp �.� i':u�ccl ff ��
�vAer: - - - • .r . . . . n I
�catton:
ibdivisivn:
t !F �.,_.-
1�Yc11 Cuxistruct�ou
v
;stanec F�o�n nc:�.sc�t i't'opecty Litic (Nlit�imui'� lt} �teet) �..._�._�__.___,,:...
�staticc from ScP�ic Systc;uz (Itiliniinurz� GQ fu::) '� Y
�c� D��cta: �o rc Yi��a: �,.�— ci�n� sc:<<:� w:�r�z- i.�v��: __�__._. i�
atcr $caring ;Gonc�: Dcptl��c_,,,;� t�c i'C _�t. .. �t�
�sinb:
:pth: Frorn �_ lo j_� 2-. [1. Diat�ictcx�: _�� i��
rpc: Galv�nized St�cl � Y
Wesght: ��.---,,,._ ���hitkncss: � I�ei�laL �bovc: Grvu►t<:_ __,Lir_ ic�
-�vc Siioc_ � Ycs � N� l�11y �iU�Il:t'I7y l:I1CC1U:�lct'c�l wliilc a�t�ir�; c;t��sl;;'? �,,,Y�� � No
`�es" bive reasoa: - -------•-----�--- -
rout:
�ieat: S.,nd/Ce;inc��t �' Cv�u:rCtc C^avc:UCciucnt
Annular S�acc WidCl: �,,,� i;aclios W;►tcr i�1 A,A��tulal' S)aCc Xes "� No
Method o�Gs-out: !'uc�apcd I'��c=ssurc_ ' I�ourc:cl Dcplla to�I��.
;aterials Uscd:
Na. Ba�;� Portlai�d ccuicnt ._. Wcight crt� l f3:��, .,,��__._ �'c�u�tids
lt I1�1X11u'C (�Al1Ci, �r�vci, cuttiaba) — itatio _„� �o �
ID plates: �, �,-�'i'cs � No � x � s!ab �-�Ycs _----1�l0
llrilli��<� i..p� �,oc:�fioj� U�-awitx�;
hereby cCTtif�f t�]at tllc �bovc iritOlill;�ti01� i5 CO.TLCZ i�T1Ci �I11i II]lS WC�J. 1�Y�S CVl1Jt�'UCECa 1[t :�CCU1'CJ�11lGC WIt72IC�L11atkO11S
�t Eortl�, by thc Pcrsoc� Couz::y klcalttz c:�:lt"h11C17;t.
•i��tut-c of Coz�tr�ctor �� _ ._ Xu 1� �,.�.��,..! 1):�tc ,� /_.��
PC1�.D tcv 41116102