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Improvements Permit (EstablishedlRecorded Lot) �_ Reinspection of Existing System (Loan Closing)
Improvements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
�Repair/Replace existing Septic System
Permit for New Well
_ Replace Existing Well
1. Permit requested by:
owner/nrosnective ow��
ome Phone #:,�
usiness Phone #:
S�
Name and adc�r� ss of current owner:
�.-/'/ �i7`4� �
: Lot size:
7. Dimensions or Proposed Structure:
���� Width: l`%
Depth: 7a' __
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?
9. Water supply type: �
private,� public ❑ community ❑ spring ❑
— Are any wells on adjoining property?Yes Q o❑
If so, identify location: on� G�%��s ��_
. Tax Map#: Jfi �`j
Parcel#: i � �
Township:�1��� r� �
. Directions to property: State Road #& Road
v ames,
oi�
dse
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Number of occupants or people to be served: .�_
10. Type of structure/facility: Proposed: �Existing: ❑
Type of dwelling:
House: ❑ Mobile Home:� Business: ❑
Type of business: ; �/�
Number of Employees:�_
Number of bedrooms: �_
Garbage Disposal? Yes ❑ No,�7
Basement? Yes ❑ No � If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
pROPOSED STRUCTURES.
I hereby make application to the PeI'SOn COunty Health Department for a site evaluation for the on-site
sewage disposal system for the above described property. I agree that the contents 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.
� �������
Signed Owner or Autho� Agent
Permit Is3��d' Lt�'
Permit Denied ❑
Plat Observed �
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Signature Date `
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_ __ _
_ __ _. ... _ . _ . ._ _ _...
< FACl'ORS-S1iE;k'VXLVA770N ; ` A1tF1lT ' ARfA2..;:` AREA3 i:A1tE.h4 >:
,_ . _ _
1. SLOPE (%) , S S S
PS O �%O PS PS PS
� U U U
2. SOIL TEXNRE (12-36 IN.) S S S S
(SANDY. LOAMY. CLAYEY. NOTE 2:1 CLAY) S � PS PS PS
� V U U
3. SOiL S7RUCfURE (12-36 IN.) S S ' S S
(CLAYEY SOILS) PS s� PS PS PS
U U U
4. SOII. DEP171(P.d.) S 5 S
P � 6 �� PS PS PS
U U U U
S. RESTRICT7VEHORIZONS(IN.) S S S S
(IMPERVIOUSSTRATA.ROCK) S � � PS PS PS
U U U
6. SOiL DRAINAG&GROUNDWA7ER S S S
(EXTERNAL & INl'ERNAI.) PS' I` I PS PS PS
Vo U U U
7. SOIL PERMEABILRY S 2 S S S
(PERCOLOATION RATt7 . S {�� PS PS PS
U U U U
8. AVAlLABLE SPACE S S S S
S d%� PS PS PS
u u u u
9. SI7ECLASSIFICATION(SEEBELO� �
SO1L SERIES
SSUITABLE PS-PROVISIONALLYSUiTABLE U-UNSUiI'ABLE
RECOMMENDATIONS/COMMENTS:
STTE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.� C:WMIPRO�DOCS�APPSEC.SMFINANCE.PC
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has 6een issued.
Tax Map # � �
Owner/Contractor
Parcel # I �
Township �'Z,l i ✓P i l
-o Date l.� - 3 - i �
Location/Address , • ��, SL� %/63, ���� (e�
G�- I si' .�y� ,� vD�.�7 �tif �h / F�
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
S.R.#
Repair Lot Area QC{��S Size of Tank �l�//�/ �f"S
SFD Mobile Home_� Size of Pump Tank NtA
Business # of Bedrooms�_ Nitrification Line L�(�� ��3 �
Max Depth Trenches_� t, "
Permits may be voided if site is
Well and Septic Layout by
Comments:
Date Installed by Approved by
Well Permit Paid WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab
Public R placement Air Vent
Site Approved � Required Well Lo�
Well Head Approved Well Tag
Grouting Approved
Comments:
Date Installed by,
Approved by
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The environmental health specialist is also not
responsible for concealed conditions on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. 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.
c:\amipro\permit.sam O1J95 rev.1.1
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION '
(Void sixty (60) months from date of issuance)
DATE: �— —�� IMPROVEMENT PERMIT #: D I
TAX MAP #: PARCEL #: I Z
OWNER/OWNER'S REPRESENTATIVE: _ Gt Y I � ro Ie'�
LOCATION/ADDRESS:
'T"l S�,,rsh 'Ib s1�� ��b�- 'T� '�''1 n✓� S(�# %%(�3 DC'_C.►i
��� c�' lsfi -��k �'n ro .� c� (o-f� � f ��'-�-=
SUBDIVISION NAlV�: �( !�l�i Gm S`j .uJ LOT #:
SECTION OR BLOCK:
AUTHORIZATION FOR CONSTRUCTION ISSUED BY:
AUTHORIZATION CONDITIONS
1. The Wastewater system construction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Permit # /(�. The
construction and installation must also meet all applicable rules and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any alterations in site or soil conditions (including structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authorization and associated pernuts.
4. Conditions:
Person Requesting:
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� SUBDIV ISIL N FOR�
WILLIAM WA�E SHAW �
MELISSA D, SHAW
T AX MAP # A-29 I-C1T 142
❑LIVE HILL T�WNSHIP
PERS�N CD., N,C.
,��snlFcation Date: ��"tz-�� � . Tax �ao �: �4��
�mount Paid� . . ' �1 � �
Rec�ir�t #: S� Pares! #: �
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�� S 4�Qrson Cauntv Health Department
Environmentai 6iealth Section
APPUCATIOPI FOR SEFtVICES
IF THE INFORMATTON IN THE APPUCATiON FOR AN IflAPROVEMENT PERMIT IS �,4LSIFIED. CtiANGED. OR THE SITE IS
ALTERED. THEN THE IIIAPR01/E�iAENi PERMtT AND AUTHORIZATfON TO CONSTRUCT SFiALL BECOME INVALID.
1) Permit r+equested by: (Ownedagerrt/prospective owner): ����,i l� "e �/ v
Home Phone:SY1- �id � Address: y3 Pir�r.,� P.v�e,
Business Phone: sq -� ��;a, 3��� QR�: �O'r's
2) Plame and address of current owner. ��� �'��P-
f �� " Ci � Prrv, P.-t�c�
�PGx/So�o
p���
3) Property Descriptlon: �.ot stze: �•a`� "'Tawnship: �:�� .
Diredions to the property J(Induding road names and numbers): � S°� ��s'�� `�/�
S7YI.sl.' ,P� ha ��� •r+l:/es �c+ c►/.:.c'l /n�'O n�. J,c;��- S+G"C.'
_ �
l,bc-F �:,r.�a �C P_,:�% �.,,,✓.,.. al.r�, /�O
4) Proposed Use and Structure Descrlption: answer each of the following questions:
a) ProposedJ� Existing0
b) � Sticfc Built ❑, Modular �, Single Wide 0, Double Wide,-�
c� Number of Bedrooms: � d) Number of occupants or people to be served: �
e) Basemen�� Yes �, No�Alf yes, # of basement fixtures: '
fl Garbage Disposal: YesJ� No ❑
g) Dimensions of Proposed Structure: Width: �, Depth:�6
� Wa�r Supply Type: Private t8 (new � orexisting �), Public �, Cammunity ❑, Spring ❑
. Are any wells on adjoining property? Yes ❑ No � If yes, focation
6) Please Indlcate Desired System i ype: (systems can be ranked in order of your preferenca)
�Cornrerttlonal _Modified Conventional _ Aitemative innovative
Other (specify):
CL�ARLY STAKE ALL CORNERS AND L1NES OF THE PROPERTY.
STAKE THE CORNERS OF �ALL PROPOSED STRUCTURES.
PLEt1SE ATTACH SURVEY PLA? OR SffE PLAfV TO Tiil3 APPL1CATiON
I hereby make apptication io the Person County Heaith Departrnent for a site evaluation for the an-site sewage disposal system for
the above-desaibed property. I agree that the contents of this application are true and represent the maximum faalities ta be
placed on the property. I understand if the site is altered ar the irrtended use clianges, the permit shall become invalid. I understand
that as applicant, I am responsib(e for identifying and marking property lines, comers and making the site acc�ssibie for the
personnel of the Persan Caunty Health Departrnerrt to conduct their evaluations. I understand that f am responsibie for notifyring the _
Health Departrnent if my property contains any wetlands as designated by the Army Carps of Engineers.
� � 3 _/� _ a��
Owrter or epresentatnre � Date
PCHD, rev.10/12/99
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PLEo4:
Tax Map #:
ApPuca�.
Lacatlon:_
New
; Imt�rovement Permit
�ition TypeofStructure .� Q��otr� I�PS��P�,Ila�%
# of Occupants 3 # of Sedrooms �
Projected Daily Fiow: _ 360 g.p.d.
Proposed Wastewater System: �i n�e�
Proposed Repair. en h'v a���oha
Pertnit
Owner or Legal
Authorized State Agent: _`
I �L
Water Suppiy WP �� .
Other System Type -u-, a-•
iit V�lid For. Five Years ❑ No Expiration �—
��- -I-r'or» �°�i- -�o�t�•^ct��h . G c.•� � IO �
P,, ���n„�ir�a Ltdv�C4u�(-
•�� Cj'
Dffie: � /
Date: �-� �'O j
The issuance of this permit by the Health Depar�m�nt in no way guarantees the issuance of other permits. The peRnit hoider is
responsible for checking with appropriate goveming bodies in meeting their requirements. This site is subject to revocation ii
the site plan, plat, or the intended use changes. The Improvement Permit shall not be affected by a change in ownership
af the site. This permit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatment and
Disposai Systams of the North Carolina Administrative Code.
• Authorization To Construc;t Wastewater Svstem (Reauired for Buiidinq Permit)
WastewaterSystemDesCription: �1yhv'vh/Co'hRi1 WastewaterFlow: 36v Q,p.d. Type:��
Facility Description: �� S\� tt, I[ Nev�,� Repair ❑ Expansion ❑
Basement? O Yes No Basemen# Fixtures? � Yes�1Vo �
Wastewater Svstem Requirements
Tankage: Septic Tank size�D00 gal. Pump Tank size "'-'' gai. Grease Trap size '""—� gal.
Trenches: Totai length D� ft. i'rench `Nidth 3 ft. Total Area % a� � sq. ft.
Max. Trench Depth: �, in. Aggregate De;pth:� in. Soil Cover. � in. Trench Separation �ft. on cenfer
Permit Expiration Date: �' � C�
Authorized State Agent Date:��
*See attached site plan and addendum pag��a r additional permit conditions. ,
The type of system permitted ❑ does ❑�s�s not differ from the type specified on the application. 1 accept the
specifications of this permi� �.
Ownedl.egal Represer�tative Signatur+e: �' Date: � / �' ��
Ot�eration Penr�it
System Type (in accordance with Table Va) � �
This system has been instailed in compiiance with applicable No�th Caroluta (3eneral Statutes, Laws and Rules for Sewage Treatmeot
and Disposal, and all conditions of fhe Improverrserrt Permit and Construction Autlwrization. Issuance af fhis permit implies no
guara�rtee ihat the system installed will iunctton prope�ly for any given period of time.
Aufhorized State Agent Date
PCHD, rev. 03l07l01
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� We�ls must � 1 a f�.et from pr��f ��- .
WeQs musf be 100 iEet from sep�c sYs�ms• . '• �
1Nelts must be at l�st 25 feet from anY bw�din9 f°und�i°�- .
Other «ro�d"tiions: �
PCti�. re+r.l�t/29199 .
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG �
Date: -
Owner. � � SR#
Location/Directi ns: � /:vc� � �o�rl��,�
Subdivision �Name: Lot #
Drilling Contractor: �e.-�� � �-�-��— �
WELL CONSTRUCTION
Distance from Nearest Properry Line ! v Distance from Source of
Pollution t G a
Total.Dep.th: Fc. Yield: GPM Static Water Level a.� Ft.
Water Bearing Zones: Depth Ft. � Ft� Ft F[.
Casin : De � th: From 6� Ft. Diameter: Inches
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TYPE: Steel � Galvanized Steel
If Steel, does owner approve: Y�s No
� � Weigh� Thickness:� '� Height� Above Ground: /�i Inches
Drive Shoe: Yes ✓ No .
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" give r�ason:
Grout: Type: Neat Sand/Cement / Coricre[e
Annular Space Width - Inches � .
Water in Annular Space: Yes No
_ .. Method: Pumped � - - Pr:ssure - Poured � - � �
Depth: Fr�m O :.o �.O Ft.
MateriaLs Used: No. Bags Portland Cement Weight of .1 bag lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes � No � � � �
4 x 4 slab Yes i No
I HEREBY CERTIFY THAT THE ABOVE INFORM�ITION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSO�t C�ui�TY HEALTH DEPART E .
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Tax �AaQ � . . P�ra:ai � ,
�• . Tan�,ns�i� � fr1� � Cti � I ..
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Suladivisio� Sec3[on: _ L� _
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: y Sys#�m Type (In Accardanc� W�h Tabie.Vaj: �
TI$IS SYS'fE�AA HAS BE�I iNSTALLL-� 1N GOINPl.lANC� 11YITi�� A►P�UCABLE NORiI�
CAiiOLlNA GEi+lE3iAL STATUTES, RUL� FaR SE�YAGE TREATNEiN1T AND DISPOSAL,
-AND �Ai.l. C�NDR10N3 OF THE 1MPROYE�AEi�iT PEi�ll�[T �•AND tANSTRUCTION
AUTi�iORRA ON. � -
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