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Applicant:
Location:
Permit Valid for �
Type of Facility:
# of Occupants �
Proposed Wastewater
Proposed Repair: �
Tax M��� i ' F�rcel #
Suhelivis�ion �
, � �� � �
Ph���se Sec�t�ion Lot � '
Improvement Permit
e Y rs _ No Expiration ✓
' : � New I'� Addition
# o Bedrooms _ Proje�ted Daily Flow ��
System:
Water Supply N/ `'�'�
g.p.d.
Type:
Type:
Owner or Legal Represe
Authorized State Agent:
The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicandproperty 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
Ru[es Lr 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 functlon satisfactorily in the future or that the water supply will remain
potable.
Authorization to Construct Wastewater System �Required for Building Permit)
* See site plan a�zd additional attachments (_).
Propos Wastewater System: 1�� ���2�llL �_ Type �v Wastewater Flow 7 6vg.p.d.
New � Repair Expansion __ p� Soil LTAR: ,�� g.p.d./ ft 2
Type of Facility: �j' �� 1�.�7t _ Basement _ Yes `�C No
Wastewater System Requirements
Tank Size: Septic Tank:. l�Gv gal Pump Tank: � gal Grease Trap: gal
Drainfield: Total Area: j2� sq ft Total Length �� ft Maximum Trench Depth Z Z in
Trench Width � ft Minimum Soil Cover: � in Minimum Trench Separation: � ft�e�'
Distribution: Distribution Box � Serial Distribution �Pressure Manifold
Authorized State Agent: _�
Permit Expiration Date:
r .�
�s, r � �'tit
Date: l9 � �"�
The type of system permitted is �Conventional Inno ative � Alternative. I accept the specifications of
the permit. �� � ����
Owner/Le�a1 Rearesentative: x /�-� G� � Date:
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S�. SS�TCI�
Name �� ""`' s� . Ta.g Ma.p #�_.Pascel # 1.��
S � io ` � Section/Lot#
_,����
t�uthorize State Agent � Date .
sy�m ��o� �,�� �������u� �y. The contractor »uuYjlag the systesn�ior to
beginning the instullation to msure thatpropergr�de is maintained .
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WELL PERNIIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map �� Parce �2 � � Township:
Applicant: �
Subdivision: C�vi` Lot #
T .nr.atinn •
Type of Water Supply: 4� Individual
�tequirements:
Site Approved By: �`1Ci ��l i l a�
Grouting Approved By: v� -
Well Log: _
Pump Tag: ���` �� n`�
Well Tag: « t
Air Vent: " -'
Hose Bib: C " !b
Casing Height: «
Concrete Slab:
Community Public
Liner:
Installed by:
Depth set: _
Grouted: _
Date:
Water Sample:
Well Driller: �,!/l�7
Well Approved by: Date:. � �%
****See Attached Site S etch**** �
;�l
Wells must be 10 feet from property lines. .
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
PCHD rev O1/27/04
vJ� �.�. 1V1�•1 � �.� � i,.. / / /���, .... .. . ...�� . . .... �u�� . a . i.n.. . ii J..UJJ: : iiUJ . .
/ r/
�--.`��, s� I�� �. � �.�:� � �° � _'- E�� . _
�`�' -�- �C � �.T1� �I�' � �c� � �� �.�.� �� �. n. r - //� � �-
IEaa.�+raro���n..c��ts�.m.1 1�3Io.a�.�vEI1n. C� � _ / -� ��6�
Owner:
Lacation:
Subdivision,
Well Log
L�t #
Tax 1��ap�� Parcei # /� 6
Well Coastrnction
I?istance From nearest Pro Line _ �
perty (�tinimum 10 feet)
Distance from Septic System (Minimum 60 feet) �
TotaI Depth: � ft Yield: � GPM Static inr'ater Level: _�_ ft
Wafer Be$tiag Zoges: Depth 1,3� ft�,� $ f� ft
Casing:
Depth: From p to ��% f}. Diameter: G�'� in
Type: Galvanized Steel � /
Weight: � Thickness: ,�� Hei�t above Gzound: ,,� in
Drive Shoe: Vi'es No A�y probl�rns encountered jvhi.Ie setting casing? Yes �-�do
If `�es" give reasoa: ^
Grout:
Neat: Sand/Cemc�nt � Concrete GraveUCement
Annular Space Width 3 inches Wat�r in Annular Space Yes �—�Io
MethodofGrout: Pumped Pressure .�oured Depth D to a--� Ft.
Materials Used:
No. Bags Portland cement Weight of 1 Bug ��_ Pounds
If mixture (sand, gravel, cuttiugs) – Rario _� to �
ID plates: _eiYes _ No 4 a 4 siab �`Yes No
Drilling Log i.ocxtiun DrawIng
I hereby certify that the above inforrnation is correct and that ttus well was constn:cted in accordance�with regul3tions
set forth by the Pe:son County Health epartment.
Signature of Contractor TD � e � 3( Bate ��_ L' ��� �
PCfiD rev 01116ip2
���y:,l,f ������
�.� � � � ����
IC ��-a �- � � u-� � �. �.�:ll IHC � .�.11 �Ila
Applica
Locatio
T�x M�p �� � P�,rc-el # �
Subciivision � • � �
Fh�se Section.Lot #
# of Bedrooms
Operation Perm it
System Type. (In Accordance With Table Va): � i�
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL , CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZATION.
Q. �i- i—D�c
Authorized State Agen Date
^ --._
Installec
�
PCHD, rev. 07/29/04
S��TYC T�AI�C 6NS���'�1�iV C�fE��IS'i (Typ�e II- N�
Tax MaQ #��� Parc�! # � 24 Systern Type (Table Va) � b .
OwmedAppilcarrt � e � Subdivision Ii�aS� �� lle �L�cic� c.
AddresslLocation 's Rd SeclPhase Lot # liv �� �
► n b S� � e.,r, d .
. .
� Septic Tani� ni a� i ca�on nes n,
V 1 • �{
State ID/date ava J Z� ' � Tt�enc� Wic�th 3 fE. `' i o�
Capa \ o O p al. �' , o Trenct�. Depth Z.2. fn. '.
Tee and Fiter ._ �� .(o Trenct� Le 2, ft.
Baffle � � � , o Trench Grade
' Seaiar�t �� ( i p Trenct� S aci�
� Riser iF a iicable �! l 1 o Rodc De and. Qual'
Tank Outlet: Seal �� o Dams/Ste owns etc. • �
Pemianent Marker �` � � Pressure Laterals
� � - Pump Tank � Hole Spadng .
�� IRiser
:e � � o e .. . . . � .
al. : ' Pipe Steeve . � . . . � .. (
/Sealarrt � Tum-u stProtectors �
�Required S�4bacics
- - � Frnm Wells •. � �
C#�ecic VaLve/Gate Valve . :
-�. i on oe . .
.� �oats/Swiict�es �: : � � .
Alarm (visable and audible)
Rate (9Pm)
ApQroved Pump Model
Btoc�c Under Pump
Pump Removal RopelCfiain
Distribution System
Serial Distribuution '
ressure an'
Low Pressure Pipe �
Appr. PiQe Material and Grade
. ,_,
_ . .��ucauEs�dasemetns.:: •
.� �t es � raina � e� a s-
. . _ . _ : . . Surface` Waters � - � - �
� Pubiic Water Su res
Verticai Cuts �>2 ft .
Water Llnes
Vehide Traffic
Easeme ' trt of 1N�
•� � p � Other
/ Eas�meMs Recorded .
I
.C�minents�
u�
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" �In
pc4�d rev. 3113I01
9
Application Date: 3 026-� q �� c� � Tax l�Iap:'�
Amount Paid: 1 0. d o ��� . ��3'� Farcel �: 1� G
Receipt#: 4 � 0�} 73 �°f 6�
C�" �^ ���� '� � 1� 1l�t�� ���
- - - :------ �� �� �l�� �' `�
,
1�� u:i•v.L'3 �v=rs.••—•-�„ «:_ �:i�t�a. aI1 IE�� �c: .�w. � o��a
�,���g��ggo� �o�' �e�'vi��5 (Septic Systems and Wells�
Sea-vac�s �e uested
� Improvemeut ��rmit (Site Evaluation) ❑ Construction Authorization
�200.00/$300.00 (if > 600 d) (Fee is de endent on the tyne of system ermitted)
'� Yloi�ile �ome �2eplacement or Building Addition �J Permit Revision
$1�0.00 (if site visit re uired) �75.00 �'
C 'b�Jeil �'ermit (l�esv/I2e�lacement/�2ep�ir) ❑ Itepair of �xisting �eptic System
$300.00/$200.00/$75.00 No Charae
�) Ser�ic�s �jequesied by:
Name: H�,AN1 � d I i c,
Address: � t S�i H,� .� �,n �•.. L 1�, r• �
2o,�vQ -� Nc. z � s � �
G� �►
Phone #(l�xe): 9 I 9- S 9 9— 9�19 2- `�
(W�w�}: 3��-59 9-.�zY�
W�iV�
2)l�am� and address o$' �urr��at a�vaaer (ii ciai�e�-W�t t�an ap�licaaat):
Name:
Address:
3) ��-oq��� �escriptnon: Lot Size: Subdivision:
Address and/or directions to Property:
�ot #:
4) �roposed Use and 'Type of Structure:
Residential Business/Type: Other b�}-�` •'� y�-� 5� S u u k- 3 v I� ct ��
Number of bedrooms �/ Number of people served (seats/employees):
Basement: Yes No (with plumbing: Yes No _�
Garbage disposal: Yes No
5) Water Supply:
Private Well (Proposed EYisting �
Community Well: Public Water System:
Are there wells on the adjoining properties? T10 Yes
(please show location on site plan}
I�Iote: A co�rtplete� amvlacation mPcsr �slso include:
���Zat/site plrzn of tlie,�ro,�eyfy tdaat s/iotv� �; o�e� disnen�iofis rand td�e siz� r��id docntioaa oj'ra11
proposec� structures.
��l .signed eapy of t/ae `�a8 ��e,�aratio�e' foo��ra veri,,�y��g �liai �l�e ps�o�e�^iy is ra�a�ly �0 5e eva�usaie�
— - - -- —
i am �ubmittan� #hns �ppiscataon to rEc�aaest servic�s #'r�aaa �he �Qr�om CoeanBy �eaflth �3epa�tffiesnt. � unde�stand #laa�
i� the �nfoa-�aa�tion �roviderl is inc�a-i Q�t or i�' #�e ��#e :s sud�s�e�a�e:n�ly alt�re�, or if #i�e inte�de� a�5e �'ha�ges, ���
per�ats and appro�a�s shall i�ecame invalid. -
�ig���u�-� (Owner/� egal ReprPsentative):
�`� ,
aiP: �l Z�I�Y
10%OS Person County �,nviroiunental Heslth, �?5 S. �iior�an �t., Suite C, R�Yboro, �iC 2757� (336-�°?-17901
� _� � � � I��
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� �� +� `� � �� � I �
�' �,.��<c�:�.:rr.,r.a.;c��.�.�j1 ��<�.�.�.'' .
�un��a��m� r'���gS�il�dfl�I IP,/g�t���c� ��ii'�Il� ���Dl�����HIleBIl�S
Tax Map #: �� 9
Appraval Req�ested for:
Applicant
Address:
Phone #'s:
Parcel#:_ I Zia
�ylobile Home Replacement
Building Adciition
Pemut Located: V Y'es No
Installation Date: � �- �- p�- Desi� flow: .3�0 (gpd)
Current Contract with Ceriiiied Operator on file (if required):
Water Supply: V Well Public or Community
Wastewater system shows na visual evidence of failure on: �- �� D q (date)
(Applicant's signature if sits visit is not required)
� ..,..-,
�
�
ed
c�rain ��2 an �¢n� � Si� �y�-
Aa�a�Il�i��3�;�Y����a��� ����°n���i
�
Enviro ntal Health Specialist � -
11/15/OS
See S� �e SK�f�� �
y- z og
Date
��� S f� ���.���
� �� � � ����
I�a�.�a�«D��«.��.��.Il IE�-3L ���►.11�tl�
Tax Map � ' P�rcel #
Su,bdivision : , � i . - -
Fhase Sect�ion Lot # ,
� Improvement Permit
Permit Valid for ✓ Five Years No Expiration
Type of Facility: �i���v,r� New _ Addition � Water Supply
# of Occupants # of Bedrooms Projected Daily Flow g.p.d.
Proposed Wastewater System: Type: _
Proposed Repair: Type: _
Permit Conditions:
Owner or Legal Representative Si
Authorized State Agent: _�
Date: � a/0 �
Date: �{- 2 0 9
The issuance of this permit by the Health Department in does not guarantee the issuance of other pemuts. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspecrions 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 �vas issued in compliance with the provisions of the North Carolina
`Laws and Rules for SewaQe Treatment and Disnosal Svstems' (15A NCAC 18A .1900). Neither Person County nor the
Environmental FIealth 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: (�/ON�n� � 4 Type ��_ Wastewater Flow �eo g.p.d.
New Repair Expansion Soil LTAR: 3 g.p.d./ ft 2
Type of Facility: �' � � c2 Basement _ Yes _ No
Wastewater System Requirements
Tank Size: Septic Tank: �gal � Pump Tank: �gal Grease Trap: �— gal
Drainfield: Total Area: sq ft Total Length (Q b, ft Maximum Trench Depth 2 Z in
o•�•
Trench Width � ft Nlinimum Soil Cover: i.a in Minimum Trench Separation: �_ ft
Distribution:
Specifications:
Distribution Box ✓ Serial Distribution
�
Authorized State Agent• —
Permit Expirati n Date: �- L- y:
Pressure Manifold
Date: �- Z '4 9
The type of system permitted is '�Conventional Accepted Alternative. I accept the specifications of the
permit.
Owner/Legal Representative: Date: o�
CHD rev. 11/10/OS
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3'Js�sn cme���ne�� ��sa°esera� �s�s�r��ai�cs��c����a�a� �aa%�, � �ae co�rfi����- nsa��� �3� .�����s�o� �a�
begiraa�rag #�ise �a.r���n �� za��a�r� yda��t��'r���ra�' as �aa�r��v�d
S��t.E � �'�--so'
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/v�e��in Ni.A�►�R'I�
'�j ►g u� Q 6a���►�� d �a,�n-�el�
c�e. � �rA�el a►•� Pa�K w�t�
�` C(p.an '' Sot � . �
�.D, ���.►n��n � �►ne wifh
aKK .�
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Loca�ion:
r
�` �� � �. f: ; '� '4, --
. S�J5�2!'fl Type (in Ac�ardanc� Wiih Ta.ble Va): � Ez
THBS 5�5i�� �A� �3Ei� in4ST�L�s7 91� C�4�IE'LL�F�C� VVtT3-9 �Prl�3CABL� . N�R?H
G'�,�Zt�L1NA G�i1��§�L ST�TiJTE�, ��U�.E� �aR Sc'�ilAC� TREATIVIE�? ��dD DlS�OSAL,
AND -�,i.i. COIVi3tT3t3PdS �� � T}-3� lI1�FF�01l��El�T ��s�i►JI1T .A�D GOf�STRUCT10i�
.�',llT�-]C)�II�TiC�,D�� � ,. , � .
Ins#alle�f. By:
� . . �"Z�_°y .
Daie
v Dat�: �- Z( -Og
,�� �D� �Z -��d� `Y.S+� ���d
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��:�'�� d �C�� �����'� � ��� �u°���a�:� a � s ;�'u�' �
Ta; Vi�p f��arc�d �/Z!� Sys�e� iype �ble �/a) �� ��Z.
O���e 1'A�piiccn� � � Subd�visio� �ose,�i 1 e
Address/L�cation Se��Ph2�� L�t � � �
Sta#e � ID/daie
Cap�ca aai.
Tee and Filie�- � �
� Baffle <
Seal�nt
� Riser (ir apA}icable)
T'2T16C OUtlef Seal
Peman�rrt tUla�icer
. P�s�a� �ank �
S$3t@ idS�i' - •
C2�a ; al.
� Watet�oroof /Se�la�# .
Riser
Water�Ti ht � .
� � ��m�
Cnec� ValvelG�ie 1!«ive
� � Anti-s� an o e
F�oais/Switches
�11arm visabie arid audible
�ecirical Components
- Rate m , .
A roved Pum iViode�
81oc� Under Pump �
Purri Removal �RopelCfi�ain
. ��i�as��su�o�: S��m
� Serial Distribution
�ressUre �8an�ro _
�.�w PressUre �'i �
Ap�r. Pi�� 1�1�e�iai ar�d G�d�
\l�lves ��
U�Jid� � 3 f�.
De�th �2 in.
Ls�ath /on �.
Tr�nct� Ga�a�+e -
Tre�cfi Sp�czng�
Roc:� De�f.� and C�ct�ifi�
�
Dam�/S���dovvn� �#c.
P�essure La�erals �
Hole Spacino �
O t3 iZf.'
Pi��. S1�ve
T��n-upslProt�iors
�qe.oi��' Se�a��
�rom� vVelis �
�rOm PTOp�E9'tV [ine.s
S€�rfa� Waters
Pubiic VVa�er ��applies
V.e�icai Ct�s (>2 �t.)
1IVa�r Lin�s
Ve�tic�� �Traf�ic � � �
Ad�a�s�t S�st�ms �
�a�esi�e�..lRigh�. of V�
O�f�a�r
�a��sn�n�s R�rd�
C�mm�n�
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