A29 147���.sf ���.���
- � � ���r�
IE��,���,�m]���.Il IE3C� � � ¢]�
Taac Map: � Parcel: (�_
Subdivision:
Applicant'sName: �QK�„ �
Mailing Address:
Phone Numbers:
WELL PEP;NII�
(New_ Repair�[) (L;,,,,�r�
Lot:
Location ofProperty: Zqi A�oQ� �viS Rc�.
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulations governing construction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.J Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:
�ermit issued by:� � .
�tew WeU:
EHS/Date
Location:
Cs�outing:
�ell Log:
l�ell Tag:
i�mp Tag:
�ir Vent:
Hose Bib:
�sing Height:
Concrete Slab:
�eil Driller:
Pamp Installer:
A�iproved by:
A+fditional Comments:
�ate Sample Collected:
�iS:
�son County Environmental Health
3�i 5. Morgan St.,Suite C
x�.,..,. n�r ��c�a
Date: �^ S— [g
Certificate of Completion .
�iner:
EHS/Date
Depth: 15'a/ " 3_$_�8
Grout: TS
DAbandonment:
Date:
Method/Nlaterials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
,,,,.,,,
WELL CONSTRUCTION RECORD (GW-1)
i. Well Contractor Information:
�'��iG Ly,tiG/�
1Yc11 Contractor Nome
�37f�
NC Well Contractor Certification Numbcr
til/.�� 1,/ z,�e�s .�'•
Company Namc
2. �Vell Constructlon Permit #:
Lis! �dl applicaGle k�el! cai.�lrtrctiat perrttits (i.e. UIC, Cnnnh�, Sture, f�iirinirce, e�c.J
3. Well Use (check«•ell use):
�2�'`�� Print Forrr
Far lntemal Use Only:
A�*ricultural �MunicipaUPublic
Geothermal (Heating/Cooling Suppiy) esidential �Yater Supply (single)
IndustriaUCommerciai �Residential Water Supply (shared) 18
�oli-�Vater Supply �Yell:
Recovery
Ttecharge QGround�vater Remediation
Storage and Recovery �Salinity Barrier
Test �Storniwater Drainage
iental Tech�ology QSubsidence Contro!
mal (Closed Loop) �Tracer
4. Date R'elt(s) Completed; v D��O �yel! ID#
Sa. �Vell Location:
N�"�YL� / oi�
I'acility90aoer\a� Pacilitv D#(ifapplicable)
,v-�jS o. e g�tt� .vG
X ,
Physical Addres , Cin•. and Zip �
Counh; Parccl Idcntificarion tio. � f'f ` i
Sb. I.atitude and lon�itude in derreeslminufcs(seconds or decimal de};rees:
(if wetl field, one I:iVlung is sufticien{�
3�° aa' a��o �: � ' ��_�,.
6. !s(are) ihe ���eil{s) Yermanent or �'femporar�
7, Ts this a repair to an etisting we1L 'es or �Nn
117it%� is u rtpair,lifl out Lnox�t tirell caun e�c r.nr iryorv�atinir ari�! e.rplain dx� nararr ul the
re��nir trndrr �ll reniarks sec�ime ��r on rl;c hurk nl tfiis lam.
R. For GeoprobelUPT or Closed-Loop Geothermai �Vclls haring thc same
constnirtion, only 1(i�1%-1 is needed. Indicate TOTAL Vli\QAF.R ai ��ells
9. Totai well depth helow land surface: ��� ({t.)
For midtiple �tirllc li:t all dcpdtc iTdrlJerent le.cumple- 3!�i;2011' �m�f ? wl �IO')
ao`.
10. Static water tevef below top of casing: ((�,�
!f Kittcr le��e! is uhoce cacing, use� "",
1 L [3orehule diameter: �f' / (i�,�
12. Well conxtruction method: d
(i.c. auger, rotar}�, cable, direet path, etc.)
�. «.
,
�. t�
ITER CASING for mult[-cased wells
7D DIAMETER
� � ft. in.
ER CASING OR TUBING eother
TO DIAb1ETER
tt. ft. tu.
ft. ft. fu.
REEN
TO � DIA�fE'[ER SL
fr. ft. in.
ft. f�. In.
AUT
TO SIATERIAL
�t. Sy f,. �
rr. rr.
R. ft.
ND/GRAVEL PACK (if applicable)
TO �lATERIaL
ft. ft.
ft. it.
ILLI\iG I.OG attach addit[onal ehe�
TO DESCRIPitOti �
ft. ft.
ft. ft.
rc, rr. �D�L .�1�G. a__.
rc. rr.
ft. 1 ft.
ft I ft.
rr. � rr.
0 �It/r l/,
�._ __ - --�—.__ . .
'.�17�'f ✓ 7�
�
�
22. Certlficatlan:
3�G___ 3 D� /c�
Si_n t e �ti IlVrlllunm.ictnr Uate
di ,� i»E tlri� n;. 1 J�rrelir e i�rliji� tluN Ihe ir�-/!/s/ •,«�c i�rer�y ronsp'uc7ed in urcnrrlaure
iriiJ� i Q A'CACO:C.UINp or �SA 11'CA� n?C_alnti 1f'eff C'onsrn�criun S7�i»�huJ. urrl tlrut d
cn/�r r�( ihi� recurd h�u beeit prnridr�! rn t!¢- �rell ui� iu•r.
23. Site diagram or additionai well details:
You may usc tl�c back of this page to provide additional �vep site details or well
con>tn�ction details. You may also atcach additional pages if necessxry,
SUB�11'I'1`AG [tiS'TKUC:'I'IO"Vti
24u. For �Ul \Vells: tiub�itit this fonn �vithin 30 days uf cumplction of �scll
con�ttuction to thc following:
Ui�ision of Water Rewurces, lntornuition Processiog Unit,
1617 Aiail Serv[ce Center, Itulel�h, NC 27699-1617
24b. For Iniection Welis: )n addition to sending the f'orm to ihe address in 24a
above, atso submit one cupy of this fonn within 30 days of completion of �veli
construction to the following:
D(vision of 1�'ater Resuurces, Underground InJection Controi Prograro,
FOR R'ATF.R St;YPLY �VELLS QtiL)': 1636 �1ail Sen�ice Center, Rafeigh,lC 27699-1636
13n. Yield (gpm) �`� �iethod of test; 24c. I�or Water Sunalv & Iniection Wel)s: In addition to scnding the form to
the address(es) above, aiso submit one caPy of this tinm within 3D days i%
13b. Disinfection type: Amount: _,�G �� co�vpletio�i of well con�truction to the county health department of the county�
where constnicted.
Fonn G1V-t
\ilrth('o�•.IinnlL.mH.n..n�..{'u...,:�...,....._._I/..._1:... ..:..•..•. •�..�. ..
�
` P�rson County Heaith Department
' �ewage System Improve�nents Permit
Date: "�`� -`3 { T'his Permit Void After 5 Years Permit #
Owner: T� r c, . 11/1 e 1 r Ss�. n! r' J S o N T SR#
Locadon/Directions: � _
Subdivision Name: Lot #
Lot Size: %� Z '�. w c � Type of Dwelling:
Water Supply: Private: —!� Pablic: Community:
Bedrooms: Z- Garbage Dispo
Basement Basement Fix
INFORMATIQ C D BY
$anj�j�: % , o ner or representative
1tEPAIR: VALUATION:
�
�
------ �
Size of Septic Tank: %(.�Q� gallons Size of Pump Tank:
Nitrification Line: _ l�1�� �� 3 � ~ -
Depth of Stone: 12 inches �'
Max Depth of Trenches:
Altemaave System: Conv. Pump LPP Pump
Remarks:
Date Well Approved:
BY
Date Sewage Sys m
BY
_ Well should be 100 ft from any sewer system
_ Sanitarian
J� — l3 — 92
— Sanitarian
..,.:..... .�ATE OF COMPLETION ,.,3
Contractor. -Ti�nM �i le �,,;s �
------------------------- �
b
Sewage System location, installadon, and protection must meet state and lceal �
regulations. Sepric tank should be pumped out every 3 to 5 years and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and ��
nitrification line must be inspected and approved by a member of the Person Counry
Health Departrnent before any portion of the installation is covered and put into use. If ��
the site plans or intended use change this permit is subject w revocation. rn �
(G.S.130 A-335F) �
i •
Location of sewage disposal sewage system sketched on bxk. �
(OVER) �
�,�_ OI�D 1UORT1� 5T� TE l�,M�S
' F�rson County Health Department �
' � WeII Permi# �
Date: �- 9Z This Permit Void After 3 Years '�
Owner:� �� 7 a .,o� �% `�C c a �, .C� SR# �1�
Locadon/Direct�ons:
Subdivision Name: ' t #
Drilling Contractor:
WELL CONSTRUCTION ►b
Distance from Nearest Property Line Distance from Source of P-�'
Pollurion� c�
Total Depth:L F� Yield: �_GPM Static Water Level Ft. �
Water ge �g Zones: De�h _�F't�FG Ft._.,,��jG_
Casin : th From U to �0 Ft Diame� � 1�Inches
TYPE: Steel Galvanizecl Steel
If Steel, does owner approve: No
Weight Thiclrness: � Height Above Ground: Inches
Drive Shoe: Yes No
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason: � ''17
Grout Type: Neat emen Concrete �
Annular Space Width Inches
Water in Annular Space: es No ,j
Method Pumped Ptes PoiuecT
Depth From —� to FG
Mazerials Used: No. Bags Portland Cement Weight of 1 bag
lbs.
If mixture (sand �avel, cpttings) - Ratio: to _
ID Plates: Yes � No ►b
4 x 4 slab Yes �� No ,.�1
I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT I
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULA ONS SET
FORTH BY THE PERSON COUNTY H TH ART NT.
�0 L-
si o Date
-s/�1/� �
Sanitarians Sig ature Date Issued
Sanitarians Signature Date Completed
Sketch well location on reverse side.
jr r;OTE: 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.
/ (1) ' (2)
1� �..ri ir � � —
Application Dute: -- l� i ,� j�jp ' Ta� I�lTa q
Amonnt Paid: � � ,� �~,,� �, �.1i�11���� f g� �
v � �aTC�t#i �
Receipt #: = (� � ����' �
:Ly'.azy3Y-�aa�a��ad�.Il 7H[aanll:EJn ;
— A,�O�lication for Sea�ices
Services �.te e�ested � ^
❑ Impe�ove�ne�t Permig (Site Eva��uafion� � r ..[�:.�onsixuct,�n Authoriaatiom
$200.00/$300.00 if> 6Q0 � d � ' � �t �'r �` : " = � ¢ . ee is d �f endent on the e of s
❑ lt�obile fl�ome dtep�acemen�;b¢� �uilding Addition ,, , ::q: �ermit Revision "
� I50.00. if site visit re uired • � � 7,�;�p � •
j� Well Penmit'(New/B,e '�Sm • a' �� -� 0 Rcpair of Eai�tSmg 8eptic System
•44nn nnta��nn nri•im�r� nn1 . � :.- —'� -� � • -- - -- —• - — - ----
t ' _ � .
1} Applicant Ya�fqr��tivn: - ' . � , . _ � . � t .' .
,
Name• ' h - V1/G�� Inl� za.r� '' 3 3�C� --32 z- 9355
�7CPhone (liome): .
•Address: • (wor�/cell): 33,l0 -5g3 ' �O ln,��
L) P1ame �nd address of curre �t owner {if ciiff;erent than applicant): `' �,
Name: L• - - " = � p Phone: �
Adc�r�ss• v'� � � � ,
. e_ � � - - � .
. �_, . �
3) ��operty IDescript�o�: Lot Size ��. U Subdivisioh: Lot #:
Address and/or directidns ta Property: �Q$ n- h��v i S Qri
� O yes ❑ no I�oes tbe site contain any j�risdicrional wetlatlds7
❑ yes ❑ no , Does th�site contain any.existing w�st�water systems?.
❑ yes ❑ no Is any wastewater going to be generated nn.the site other than domestic sewage? •
0 yes ❑ no Is the site subjecr to approval by any other public agency?
❑ yes � no ' Are there any easements or right of ways on this pmperty?
.(if `yes' is checked, please provide supporting documentation) '
�) Proposed Use,aad �ype of �4ructure: �. =
DResideatial . ' •. _�
I� New Single Family Residence Ma�amum number of bedraoms: / Occupants:
� Expansion of Fxisting System If expansion: Cucrent number of bedrooms:
❑ Repair to Malfunctioning System Will there.lie a basement7 � yes C] no With plumbing fixtures? ❑ yes � no
�Non-ResIdential _ - - ' •
Type o€ business: ' Total Sguare footage of Building
Maximum number of employees: Ma��iium numb�r of seats: --
. -
5} 1�Tater S�apply: ❑ New well ❑ Existing We1I� L7 Community Well � Public Water ' � Spring'�;
Are there any existing wells, springs, or existing waterlines on this properiy7 O yes ❑ no
Please note any Imown ground water restrictions or sources of contaminatian; '� •
�-- .
6) If applyi�ag for �Au�orazation �a Construct', please fridieate prefgrped system type(s):
❑ Canventional ❑ Accepted Cl Innovative � Alternative � Othet - ❑ Any
�. . . . .
I cert� that the infonr:ation provided above is complete and correc� I also ztnderstand that �tlie infonnation provBded is
inaccurate, tfie site is subsequently alterec� or the intended use chgnges, all permits and approval.�sliall be invalid.
:\ ..
02 - � �- 3-�e`/�
Signa (Owner/ Legal Representative*) ��t�
"` Supporting documentation reyuired.
o�erynu�s are v�lid for eithe� 60 months �r are non-egpiring w�en accomp��ied bq an apppoved pla�.
0. A completed `iot Preparation' form must accompany any applieatian reqtai�ing a site evaluation.
c
�.,��,s r ���.����
�- � � ���°�
IE������.m���.11 IHC�mfl¢l�
Tax Map: �Z� Parcel: �
Subdivision:
WELL PERNIIT
(New_ RePairl�)
Lot:
Applicant's Name: � �
Mailing Address: �
S7�
Phone Numbers: , � ����—Co� ?-�/p %��� 6'�r�C>
L.
Location of Property:
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable SYate and Counry regulations governing construction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments:
Permit issued by: Date: ! �
Certificate of Completion
Qlview WeU: � iner:
EHS/Date • EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmenta) Health
325 S. Morgan St.,Suite C
Raxboro, NC 27573
Depth:
Grout:
QAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
�'
Phone:336-597-1790 Fax:33C�597-7808
11/26/13 '"
Amount paid (�" �3 —� / -
Receipt �i � Date
�ermit requested by: . . .
�wner/prospective owner/agent: u� -
Address: � �g
Home Phone #: 3�� S�7 36�0
�
a
Q
�
d
H
usiness Phone #:
. Name and address of current owner:
W
�
z
Property Description: Lot size: �� L Z
Tax Map#: �Z� �
Parcel#: /y% � ,
Township:_
Directions.to property: State Road #& Road
ames,�tc.
�
7. Dimensions or Proposed S[ructure:
W idth: _�f`
�Depth: %i`/ �i�,�,�,.
8. What type (if any, additions, expansions, or I
replacement is anticipated to the structure or facility
that this sewage disposal system is"in[ended to serve?
� �,r�i
9. Water supply t}•pe:
private � . public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ I`Io [�
�If so, identify location: �
. Type of structure/facility: Proposed: C]Existing: Q j
Type of dwelling: �
House: ❑ Mobile Home: ❑ Business: ❑ �
Type of business: '
Number of Employees:
Number of bedrooms: _
Garbage Disposal? Yes O No �7 '.
Basement? Yes❑ NoL� If so, # of basemenc fixtures: �
6 I�Iumber of occupants or people to be served: �
CLEARLY STA� AT..L CORNERS OF THE PROPERTY Ai�ID THE CORNERS OF ALL
PROPOSED STRUC'�URFS•
I hereby make application to the Pet'SOn C011nty �ealt�l Depaxtment for a site evaluation fon ahe �niel,�
sewage disposal system for the above described property. I agree that the contents of th�s applicati
and represent the maximum facilities to be p]aced on the propercy. 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 l
issued, I must presen[ a survey plat of the property to the Health Dept. I understand that in the evenc I have no
delivered a survey plal of the property to-che Health Dept. wi�in 60 AAYS after the date of the evaluation of
the site by the I-ieaith Dept., this application shall become void and all fees paid forfeited.
Signc, Owner or u orized Agenl
,emnit Issued ❑
�ermi[ Denied ❑
?]at Ob'served ❑
S ignature
Date
.
,,. ,� . . . .... ..
.. � ��t
s."�'�'��c���''H��Ci'bRs$IYEEti!ALVA. _ s :��. ���E��� x.�,�s���:;i,��.E'�ti,x .�.�.Yi'��`„�� `� ��;�, ��� �s � � �
..�T - .i`. �Y.:
1. SLAPE (x)+ S S � S S
PS PS PS p$
U U. ' U V
2 SOII.7F7Cil1AE(12•)61N.) —• $ S S' S
(SA?:DY. L0J1MY. MYEY. t+OTE 2:1 RAI� tS ps �� ps ps •
V U U U '
3- SOiI.SIRl1C7URE(I1-361N.1 S S S S '
«� �� PS PS K PS -
U U U U
i SOILDEY7}{(W.) S S S S
PS ' PS IS PS
v u u u
S.RES'IRICfiNEHORRANS(Rt.) S S ._ S . S.
(II�{Pf]tV10USSilKTA.ROCK) K PS . tT PS
V v v v
6. SOA,DSWNA4�JGROVNDWA7ER S , S S S.
(DC'[ERNAI. � Q(�IIWIIL) ps ps n p�
u • U U U
7. SOfLpflt}�g/lgi�y S S S S
(PfRCOL0J1T10N RJ17� PS M K PS
� - � U V U
� AVARAS[ESp110E . S' S S S,
� ps PS TS PS
U U U . V
9, SiT&M$STF7Cll770N(SEEBELOV�
SOTI,SERIE� • . •
• �
SSUITAIILE TS.iROYISTOttALLYSU[TADLE t�tmSUliAau
r„-..-.,... - -
��.vnnn��NllATIONS/COMMENTS: '
SITE CLASSZFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, f11
areas, wells, water bodieS, slope patterns, etc.) � C1AMtPRO�DOCSV�PPSEC.SFI��NCEPC
�
e
Person c:ounty Health Department
Existinq Sewage System Report For: Nobile Home Heplacement
✓ Addition �q„�tr��,
t /�� n/
Requestee: ����0. .�/ v ��°�� / Vc��s�n Kome Phone# �'��7C�
�� $ % Y C:Q�r�, ��,�1; S �G�l • Businessx
� G�` Tax Map# �l " `� �
Location/Uirections: - l � �T/L �-h `� 1��� f�` --
�a9�
Original Per;ait Located Lr
0
Septic Systera Uesigned � or:
Kesidential �- I3usiness
Other (speci�yl
# f3edrooms � # Employees Other _
llate lnstalled 1�-�3� � Water supply
Type oi System �1%��'��1-Q��
Hitrification Line � ��c�J �/� ��
Tank Size
Certified Operator Required
On site wasL-ewater disposal system showes no visually apparent
malfunction on
Yermission is granted to:
According to the attached site plan.
Comments:
�
SC `-�
� �� 7 z3-95�
Environmental Health $'�G. o'^'-
DATE
�..
- --..: -. .
m
_ ��
s. R, ►141 .
. _ _� .
AQpiication Date: o -�� "� -1
Amount Paid• 1
Rec�ipt #: 2 R'�F 3
�# .
►a�3
Tax Map #: � °Z �
Parca! #: � � /
`--���_ � ���..� ��
' �C � �J�T'�' �
�EaaTa.r.��--- ---- �eaa��o.Il. �o.m.n.�I�a.
APPUCATION FOR SEiiViC�S �
IF THE INFORMATION IN THE APPLICATI�N FOR AN IMPROVE�VIENT PERMR IS INCORRECT FALS1FiED
CNANGED. OR THE SITE' IS ALTERED. THEiV THE IMPROVEiNENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID.
1) Permit requested by: (Ownerlagentlprospective ownerj� ' , ��
Home Phone:3hy-/o5 3 Address: �
Business Phone: 3 G y/o S 3 �
2� Name and.address of current owner: /��6 �U z.q iUel r..nr— D
� � � �nr,h 1�� ff�dl .
3) Ptoperty Description: Lot size: ./ 2Z- Township:
Directions to the propefii llncludinq road names and
S
Lot �
4) F�ropased Use and Structure Description: answer each of the followi �q questions:
a) Proposed `, Existing . Type of Strucfure• Width:�Z �_ Depth:,�_
b) Number of Bedrooms• Number of ocr.vp nts or peo le to b served: 2 y ' a�f
c) Basemen� Yes �i o_ Will there be piumbing in the basement?�
d) �arbage Disposal: Yes . No �
5) Water Suppiy Type: Private `�(new _ or eacisting�, Public� Communiiy , Spring _.
Are any weiis on adjoining property? Yes_ No �If yes, please indicate approximate locatiori on the
'siie plan.
6) Does your properly cantain previcusiy iderrtified jurisdlctionai wetlands? Yes_ No `�
PLEASE NOTE THE FOLLOWING:
➢ A Pl.AT OF THE PROPE32TY OR SiTE PLAN MUST BE SUBMITTEfl WITH THIS APPLlCAT10N.
➢ PROPEi�TY LlNES AND CORNERS MUST BE CLEARLY MARl�D. •
➢ THE PROPOSED LOCATiON OF ALL STRUCTURES MUST BE STAkED OR FLAGG�D,
➢ THE S1TE MUST BE READILY ACCESSIBl.E FOR AN EVALUATION BY THE HEALTH DEPARTME�IT
STAF�.
I hereby make application to the Person Caunty Heaith Department for a site evalua6on for the on-site sewage disposai
system for the a6ove-described property. I agree that the contents of this application are true and represent the maximum
faciiities to be piaced on the property. I understand ii the siie is aitered or the intended use changes, the permii shall
became invaiid. � ,
or
f ��y-� y
Date
PCHD, rev. 06I27102
� :_.
0
0
-- _ - :�� � .� �•�� ��. �� �
��,
- _ c �,� � - -�: - � - � �
I: i:�. .,... (,�..�,. I' _ I !: t� -_[, l i:...,
I
� .. .. -
. �i .�. � .
!� s�� � '1s.yi\ �' • �'1 - f�l '4'. 1 �-t � �. �- �� � �i� � . M�at�..�y,t.t
- - T . . .,,. ,,� � • kI�/' � / /. ' �
• ,
�c. �.�a �.. �. - I .�� � i, i . � `� r�i �� - ` �.�..cij .- �
_ ,
�L . .i��..�. ��� : , ;�,, ;� � �
,li� ,I
��w�,�,�
�'
�sigig�ai Pes�ait Lo�: '� �a� SnPp�Y:
Se�tic 5pst�m I3� Fo� � Besid�ataai �nsoaese Ot�aer .
# B�� 2 # �� � � � �
. `� �
� . s� Tyr�: ��tue. � �� s� � C� i�r�� � �c�� :`�
_ . . �� �n�:. lc� —13 `�'iZ. � c� �� �q�: . � .
on-� ��� a�� � � � :� � �����a � �— ��u� :
���� � �� �:
C� �� � �l � ���-1 ` c�c���-�— �C l y ' �(,2� �
� -..��� �� ����,.�P�� �,,�� h�. �—W���e�P�_ b�� -
• '�
. C�..L•
�
� ��h � ����
y �h � . S�
� �rikR i,Q�.t S�i,t
. �
�Y+o•��*+�1 �eaith Spe�i�dis�t i3at� ��l ��
,
6
����� .) �� � ��
,'1l . � �
�� � � ����
I��.�.a-��.-�.-„-n ����.]1 IL���.]1�I�.
Applicant: o��ceS ��11 i✓a4�'c� io �i'(� T� f l�lSovL
Location:
� f,1x Vi S
I
T��x Nl��� P�rcel +
S�u�bciiivi�s�ion
Ph�a�se Section Lo�t #
Improvement Permit
Permit Valid for Five Years _ No Ezpiration
Type of Facility:
# of Occupants
Proposed Wastewater System:
Proposed Repair:
' New Addition Water Supply
# of Bedrooms Projected Daily Flow g.p.d.
Type:
Type:
Owner or Legal Representative
Authorized Sta.te Agent:
� Date:
Date:
The issuance of this permit by the Health Department in does not guarautee the issuance of other pemuts. It is the responsibility of the
applicanbproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met This
Improvement P.ermit 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 `Luws and
Rules for Sewage Trealment 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.
Autho.rization to Construct Wastewater System �Required for Building Permit)
* See site plan and additional attachments (_)
Proposed Wastewater
New � Repair
Type of Facility: �
�S�'��
Tank Size: Septic Tank: gal
f �¢1�1�v�i c� � Type �,� Wastewater Flow 2� g.p.d.
_ Soil LTAR: � 3 a g.p.d./ ft 2
;� � , Basement Yes 1�No
Wastewater System Requirements
Pnmp Tank: °— gal Crrease Trap: gal
Drainfield: Total Area: � sq ft Total Length �'D ft Mazimum Trench Depth �_ in
Trench Width � ft Minimum Soil Cover: �_ in Minimum Trench Separation: �_ ft(9 -C-,
Distribution: Distribution Box
Specifications: �— ��'S yt
0 "
Authorized State Agent: �-c
Permit Exnira on Date:
� Serial Distribution Pressure Manifold
The type of system permitted is �-Eonventional
the permit.
Owner/Legal Representahve:
Date: — =fl
Innovative Alternative. I accept the specifications of
Date:
PCHD7/30/2002
� •
.
�1� ?, )� ���� �� .
' � . • � �.����� .
]E��a-m�� ,.,,... ���.Il ' IE�tma.Il�]{a.
��� i� `�"��'u� 5��, srrE P�v
N � l�( � (�'-��'L Taz Map #� Parce.� # ��`
S ' n Sarion/I,ot#
Authorized Siate Ageat �
�� �'P"�� �t'PP�tt °0i�°ura mlp. The caanacmrmast9sg rl�e syssm pant ao begiaarag �e ias�IIadna av
ia.siae r6atPmPergrad°ism�mniaed
� ��u � eX�S-F; ��
a,�� I�acK4; �(
I� �e �
�p �, ,Nl �vo�
c��a�, ���QY .
�
, . . �s �l� .
,�n ���
�"J� `
� � ��-t�'�o.
. �d�� �e�
� .
rc�m,,�. a���z/oi
���, ; , �� ���� ��
�_. � ...�^ � � � � � 1L
I���n�-���.��.�.�.Il IC-3L �.m.11�11�
Appiicant:
Location:
/,
Tax M�p � F�rcei #
Subdivision
Ph�se Sect�ion Lot #
# of Bed�rooms
Operation -Perr��t �
System Type (In Accordance With Table Va):
�'a
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
AUTHO ATION.
��� � �
Authorized State Agent Date
� �►
Installed By: � � � Date: 7��2'��
��
� �
��� �� -k�x-a-
i`� ` �..,,���
�
�
-G� "c
�: �.�9�
-----�.
� a�`a c�vr?f� ��0��
,1,�`'• s
1�
: _ ��,�, ��
��� w
�-�:
�
�
1
s'�'
� ��
� �
�1t[ =1��, t�l1'�liC=�l��=�i
- , 11• _ �.
ri�� D7i�r=F �_�
_ •'='�"!�
r7�=:�a_i� aj �++., _ r1E1
_ �
[=t��Lt �i
_ 11 r�...
�r: ;� = t-
N�ia��;��� ��s �
�r_iF:. 1 �.11t r�t'�
— 4t) .�f2Y_ •:�— _.f 1• —
;=:i�1�-;�= f'�i��'� i�%���
SI[_ •{�1�1
•
� .'���l�+
,�, _ "�•
�si�
��
c t• ��i•
�!":`�:'�Tr1
�r_
0
- , (-' � f ', !� I �l�� I F�� �ii�1
- . � _' t =: 1 � -.,
� sl i� �r'1{'.
� • •i-^ ♦-:+� _ i�-�: [=:fi'�
i� �irr��
�_�' �-��_'�_=,H'.-'41�.�za�,sl i •:
-�. .��� •i a•�:.
���� ��:_-_:�1'�=:�1'..: -��a.jL'=
� t!T e f i i"t�;i?.�r=; �.��1�
A�alicationDate: 3"���� � ' TaxMaa#•
Amount Paid: �
RecEtpt #: ParcE! #:
•`.������ ��� ���� ��
- - _ --� � � �.7� ��
� a9_vaa-���-�--^ oaa�.m.I1 ��o.ao.7l�l�a
� APPLICATION FOR SERVtC�S ,
IF THE INFORMATION IN 'iHE APPLICATION FOR AN IMPROVEMEi�T PERMIT IS INCaRRECT,_Fi4LS1FiED,
CHANGED OEi THE SITE IS ALTERED. THE3V THE 1MPROVENiEAIT PERhAIT AND AUTHORIZATIOtd TO
CONSTRUCT SHALL BECOME INVALID. �
1) Permit requested by: (Ownedagentlprospective owner): �- 5�-��. � � �t�`-`�c�Cs
Home Phane:��`�'4Zi�l(¢4 � Address: 32C,� �se g '^�►-e_-
Business Phone: �t4-?3v• t��� v� �.,.,,,� _ � .��i2
�)
3)
Name and address of currer�t owner.��� 'X
� Z.9 �h avt
Praperty Description: Lot size: (,� �e Township: ��r�`6� Subdivisii
Directions to the pro�erty (lncludingroad names and numbecs�: �, w
��� Lot # �2� . ��� l��l
4) proposed Use and $tructure Description: answer each f, e foliowing questions: � / ,
a) Proposed � Exis�ng �, Type of Structure: (�:�����n Width: �� Depth: 1�i" ��
b) Number of BedFooms: ,�_� �. Number of occupants or people to be served: � �,,��� ��C-�� �
c) Basement Ye�_, No � Will there be plumbing in the basement?¢�o � W�l� W�
d) �arbage Disposal: Yes ��; No O .
5) Water Supply� Type: Private _(new _ or existing�, Public� Community� , Spring _
Are any wells o� adjoining property? Yes No _ ff yes, piease indicate approximate location on the
'site plan. � . �
S) Does your property cantaln previously identified jurisdictional wetlands? Yes_ No,�„
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPEi2T1( OR SITE PLAN MUST BE SUBMfiTE� WITH TH1S APPLICATIOM.
➢ PROPE�tTY LINES AND CORNERS MUST BE CLEARLY MARKED..- ,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE ST�D OR FLAGGED.
5� THE SITE NillST BE READILY ACCESSiBLE FOR AN EVALUATIOPIBY THE HEALTH DEP�►RTMEiVT
STAF�': � .
I hereby make application to the Person County Heaith Department for a site evaluation for the on-siie sewage disposai
system for-the above-described property. I agree that the_ cantents of this appiic�tion are true and represent the maximum
faciiities tfl be piaced on the prop rty. I understand if the site is aitered or the intended use cfianges, the permii shail
became invalid� _ /1 �
or'�gal Representative
3-2� �07
Date
PCND, rav. 06127/02
� ��}�.�'4 ��y�•�,� `�i.0 1 �4 � � .i/+'
+
�.i �.
� ; �� T 3.��" t � �^ f`�� ��'i:l
�..,, a.,� ��, k . ; �
w.�.� , > �,. ,,., ».�,. . .. .
.
z•sn� ..:.._ ...,_..��_�.� . .K.a�..�... .,�. r.-,-..,.�.,� ,.,» ..............
Bu�hy For6� T��p. , Person Ca. , N. C.
June , 1992 I" � 5 0'
� o' 0 30' ioo'
�
.� -
�rn�s� �. Waod,�. , R LS - 264�8, Roxb�ro, P�. �. �
� lhatihe:v D. YJode
�\ � D. B. 203 -621
\\
�
� .
i � .
J. Sidney Wade
D. B. 70 - 4 �
� . . ._ za�.r�.r�rc.�+ .r.ss�aa - - — . .. .
p. . _, .. . . _ . . .. _ ... - � . .
�� �
� ��� �
'�,..�... ,!, �'"�"�� �../ � �.J �. V � �
.li��]rll.�'71.I�'QD7TIl.3L7CD..�]L7L'�•�.� ��:d�i.,�t��.
Building Additions/ Mobile Home Replacements
Tax Map #:�_
Approval Requested for:
Parcel#:
Mobile Home Replacement
_� Building Addition
Applicant Name:
Address: " �1i� t�1 j�,'�u�� i�
�2�xk��ti lc a�-��l
Phone #'s: � tq - �-�c� _c� t�9
Cscvtt R�\� b:���Ciex��
Pernut Located: _� ✓ Yes No
Installation Date: �- �� - v� Design flow: ��O (gpd)
Current Contract with Certified Operator on file (if required): N�
Water Supply: � Well Public or Community
Wastewater system shows no visual evidence of failure on: �3 0� ate)
(Applicant's signature if site visit is not required)
Addition/Replacem�nt Approved
,� , ��-
Environmental Health Specialist
11/15/OS
'ti
.�"���
Date