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Improvements Permit. (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing)
'impxovements Permit (Unrecorded Lot) _ Repair/Replace existing Septic System
Improvements Permit (Mobile Home Replace) _ Permit for New Well
Improvements Permit (Addition) _ Replace Existing Well
� � ,.;�:.>� �:�; � -.:x.:�. F ,�.N.,,; _ .��.- .. . .::..... . .... ..... ...._ _ _
B acteria _ Chemical Petroleum _. Pesticide _ Lead
1. Permit requested by: . � 7. Dimensions or Proposed Structure:
�wner/prospective owner/agent: ��55��� Width: _
¢
z
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?
ome Phone #: . �
usiness Phone #: %� ��d
. Name and address of:current owner: 9. Water supply t}pe:
�_ _ private � . public ❑ community ❑ spring ❑
- ' - Are any wells on adjoining propeRy?Yes ❑ No [�.
If so, identify location:
ion: Lot size:
Tax Map#:�/.7r
Parcel#• � -
_ .. �. �-,..
�I
. Directions to property: State Road #& Road
ames;�tc.
Number of
or people to be served:
��
10. Type of structure/facility: Proposed: xisting: Q I
`Type of dwelli
House: Mobile Home: C� Business: ❑
Type of business:
Number of Employees: 3
Number of bedrooms: _
Garbage Disposal? Yes ❑ No �
Bascmcnt? Ycs ❑ Noi� I� so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pet'Son COunty Health Depal'tment 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.
Signc� Owner or Authorized Agent
Permit Issued ❑
Permit Denied ❑
Plat Observed ❑
� 9 _-;� �- � � . , � �, . .,-�.
Signature Date
SOII.7'F�(7VRE (12-36 iN.)
7'
�itDY. LOAMY. CLIYEY. NOTE 2:1 CLJ11n
SOII. STRUCiURE (1 b36 IN.1
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RES7RIC17VE HORCLONS (iN.)
dPQtVi0t1S SiRATA. ROCK)
SOA. DRAiNAGFJGROUND�'1ATER
x,�,►�.��w�
soa.r�+�►s�urY
exxcoco�nox x�re�
AVAQJIBLESPACE
S(iECLASSiFICATION(SEE BELOW)
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S-SNTADLE TS-PROVISIONALLYSUITAB(.E U•UNSUTCABLE
RECOMMENDATIONS/COMMENTS :
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SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.� C:�AM[PRO�DOCSAPPSEC.5�1 FWANCEPC
�
!
Tax Nap #:
��9 —
APPiicanC ,
t.ocauon: _
Subdivlalon:
PEi�SON �OUNTI( E3VVIRONME�ITAL I�EALTH
r�
;
��,�__ l�9 �
��P C�/� � � l �-;' I ��
0
0
s�lon: I.ot J
�'O�� � Gt//"Pilil �
Sc��
� tmprovement Perinit
A buildina aermit cannot be issued with only an Imarovement Pennit
New r� Repair Addition Type of Strudure S� � Water Supply /' �✓� 4���
# of Oax�paMs S� �#•of Bedrooms Other
Basement? ,Q�_ Basemerrt Fudures� .
Projeded Da�y Flow: "36A g.p.d. Pe d V id F r. �F'ae Years 0 No Exp'aation
Proposed Wastewater System Type: u�, :_ . z
Pump Required?� ►/ Yes No j
Proposed Repair : �. n. ��-��ur2.��.- �s��y=J
Permit Ccnditions: �
�S'C�� S��'T-2 s/�P ��/l n�r t.�G%C'���/�inct� �Y'�/i�%- ���'LG�l� � /Ah C �/��K6'i�sn-
crqPs
Owner o� Legal Represerrtative SigAabure: ^ o.� Date: ./
Authom.ed State Agent � Date: � � D
The issuance of this pertnit by the Health Departrnent in no way guatantees the issuance of other percnits. The pesmit
holder is responsible for chedcing with appropriate goveming bodies in meetlng their requirements. This sifie Is
subject to revocation if the site plan, plat, or the inteaded use cl�angea. The improvement PeRnit shall not be
affected by a change in ownersfiip of the site. This permit is subject to campltance with the provisions of the
Laws and Ruies for Sewage Treatrnent and Disposal Systems of the North CaroUna Adminlstrative Code.
Author9zation To Construct Wastewater Svstem (Reauired fo� Buiiding Pertnitl
Type of Wastewater System u� 7� `�riV p•i� ji �1�/�ater Flow; 36 o d.
�/�es .� �.�:
b —g.p.
Fac�iiy Type: 313�Z �rs. ��.-�—� New tt�Repair OExpansian 0
Basement? 0 Yes C�'No Basement Fixttues? Q Yes @'N�"o
Wastewater Svstem Reauirements ' -
Sep�c Tank Size• i d 4 O gancns Pump Tank Size• 44 � gaqons
Total.Trench Length: 6 D fieet Maximum Trench Depth:1� inci�es A99regate Depth:L in.
�-Soil Cover. 6 inct�es
Q��,
Tcench Separation• % Feet on C�nter
�s /- `f � � �- ��/ ;,,�`��.�,�.�.�,/'��s
Permit Expiratton Date: � — / — O
Authorized State Agen� (��; � � / -,�/
The type af system permitted � does � does not differ irom the type sperafied on the appiicaticn. I acs2pt
the specificatians of this pertnit ,
OwnedLegal Represantative Stgnature: _ � ^'� pa�; •
PCND, rev.11/18/99
J�d�-e �� �
. . _----.- ... . __...__--�--..__._. .... ... _.. . .
��r9�n C�unty Neaitta. �epact�nent
. � ��vir�nmenfi�aa Hesitl� Seciior� '�ax 91�ap �: : �% � _
� � . � � P�rcai �: 1 � ��
� Si'�'� 514�YCt� � - . . . --
�}- -7 ' �P.sse l��'l/ �,D � �.S'
%�q� � � .�,bra !� � ry► .
ApQllc:arrt's Name . Subdhrision/Sec�ion/Loi�
• _�` �,5. �- /9-O/ , .
. Authorized Stafie Agent Dete
g� +�� nPr�rt aPProadna� cmrm"'rs a'l�'. Tdrs cn,drador mrmrlla� t11rs sya�re
priar m�g tba �a io � tbat pmPerArade tt �
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cir
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s<itil�b.L //tS�//�G/ �7�� �d•s (Lcir��G1,'{�O�s/.$��O[J/i
1�10�.
2) ? 6"� G,�o« 1I or � Solls/�,�//,� re c���P��c ,� /��
�Ver Pv�D�ire �sy.s7����� �'�tn/eX��iz ���g''/a7��.-�/�
,�j�yonc�( �r�i�` Si�E'c..J�ci/S.
✓ / ,J 'I� /� yy11 /1
3� �� �G�G'E'F,�i/�.H't Gt-�PS .Z -� T 7`�r"�G��'+"�P CY D/'PSSGI/-�
,/ _ ,�_� i/ �
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/
297 `
G
PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #• �� Parcel # � ��
Zoning
�_ Township
ApplicanC t�Sc n/l/11 a,� " �,G� /�f �Mr r�n
Lowtlon:
� s .� �"
Subdivislon: '� � Sectton: Lot
Well Permit
T e of Water Su i: D' Individual Community Public
ReQuirements•
Site Approved by �`��
Grouting Ap roved by � " ��oJ
Well Log � I+ - i-o�
Weli Tag /�� "� �� �
Air Vent Mn%��'� "�� � ��I
�
Hose Bib � -B�
Concrete Iab���'�l
Well Dritler: �a�'' � �
Well Approved By: .--��'`' -
Date: � �����
**See Attached Site Sketch**
Wells must be 10 feet from property fines.
Wells must be 100 feet from septic systems.
Welis must be �at least 25 feet from any building foundation.
Other conditions:
PCHD, rev. 11/29/99
s,
$� ALC�tEd SitE�C FOC �eCn1C31
Specificatioc�s
1
6"
� � ��
_ !1� = 111 = �11
111 = f 1 �= Iit =
�'� 1�� = t �i = � tl
�_.��. ,. .
. � • .' • '
tJndetgto�d Cable In Cac,dui.t
With Suitable Sealer Ir� Boch
Ends Of Cac�uit
�,_.�� �._... _...-
. - ._ .. �. ..
■�i �� r • . r - � • i •�e'
. - -. .. _� . , .- _..., � .
t^ 1
c�yr�r� a � Spnein� /
.v/Q" � ��' ""�P J Da�le
�Yo�DO���l�vr" L'yCle,
! /
=�r �
�:t-
Submersible �e
Efflc�ent Ptnp ��•�a
8" Cancrete
Block
:.
-_�. �� �,.�1
�.,.._
_ � �$31r�1e
�`.
� � ��� z� �. �
' �ri�i� r_i�c• =i • - -� � .�� _�
hi � si �r«• �ca �i � '�ar_• n�
i r -� r _i � •�r�. �- _
inish Grade '
1 1 IN � I �
" Itl = ��i = ilj = �t! = 1it -
-
��� = ��� _ ��� _ ��� = ���
111= i�t,_ It1,= tt1 ` �.;_..��'`":.
, � --
• . . . � :�=
• . 30�• � �Gallaa T�lc
, ,• I
� �
. �
. �• �
. E--�PPIy Line ?o . ,.P�� "• � ��
� ► Dianeter SeheduTe 40 PVC
... '• pi�
ltn Anp Retr�t�al. �
•• • Gate Va1.ve
' � 'Ihreaded Uriiae
• Qzeck VaLve
3/16" 5ypt�n B� ��ole
� � ?�dd�xf Str� Ara�i Aytl Q�.ls
� Alazm Float (elevation)
"R� On" Float (eievation)
' ' "PucQ OfP' Float ielevat�-on)
��
� I � .
. . . , a a
a A ' • .. , � d • . • • • . a � � • •� • � � �
. � s
�is T�is St�.11 1� af a si� P�vua3 RztP 'I�k �
I�i�n �rl s�l]. be T.�tc �t�3 ar�i.�
PUMP SYSTEM DETAIL SHEET
PUMP RATING
Pump Mus Be Rated To Deliver
� Gallocss Yer Minute
Against �Feet Of Tota
Dynamic Head (TDH)•
See Folloving Sheet For
Additional Specifications,
Notes, And Explana[ioas.
*Block. Brick
or poured
*Cleanout Piu¢
*Note: Cleanout olue adapted to accomodate
stand pipe to adjost pressure head, or and
additional tap may be used to accomodate a
stand pipe for pressure hwd adjustment
/
�2 in. Threaded Tap or
saddle tap Sch. 40 PVC
Sch. 80
PYC
Pressure Head to be set at � ft.
�
Taps and �
valves
Mechanical
Cannector
Nitrification
i1wY
PRESSURE I�IANIFOLD DETAIL r°`%� 3��
SIDE VIEW
� in. Manifold
. _ Sch. 80 PVC
From
Dosine
Tank
Support Straps
Concrete Pad. Le�•el
END V1EW
Gate Valve
To Nitrification Lines
Suppvrt Strap
Support Block
Concrete Pad, 1,evel
TOP VIE�V
ig
i
ng
Y1� �.essu_: :rea��� t ...•.•• e•
r
�7QSL �?: ?QC:Y3:�'GL �
� «r
iiB� 4% . � �
3nclasare
i�ater tight �
+
cccroslon
stall : circnit cesl9tant �
scannecL sQitc� �
panel does aat � �
ve a dead fraat :' ..:.._:a � /
�� �annal 3iscoanec�. :a: `• . /
ate: � SreaYer does �::c::: �
t canstitnte a � , \
scannect) � � i" to
�
. fiaish grade�
�nap .;apply circni� �
�lara Cizeait
3aCar 'ighc izal. — -�
� Hqdrauli;. ceaeat� •
Sc�edule s9 ?QC — —
Snpniy �— -- �--
�iq�vback pluc3 and Receptacle
_ �,.
�IA pressare treated , �
post ar eqnivalent
0
0
0
Z' �iaiana
Gas 'iqtit
Coadnit
�>iZ' to finisb �rade
• paap scpply circait
alari eantrol
.
�ater Piqht Seal
Hydranlic Cenent — —
Harness �:cess Cards — �
� � Sc�edule 42 ?VC
. Sagplq
,��-,��rf�
Simplex Control
Panel Wit�
Built In Alarm
Iate: lhis is
nat a virinq
diaqrai! Consnit
an 8lectriciae! -'
Dact Seal
_ �
�
: / '.ackiaq S�_a�s
� � 3araess Szc�ss �_a:is
� ---
fleceptac:e �nst 6e
iotar :ated
�o�-Paltaqe alars
' caaaectian
Uuct Seal
:',he �Iata aus� �e
�ount;d i: :5z z:si�a�=
liviaq �rea ��L :he
dve'_:_�g ;aat in- ��e
craYi ;pace qaraqe a:
nnde: a ao6ile �oae; �
Phe paael �nst be audi�l:
and �isi�le to� spsta� :sers
Lackisg straps
�
""'r.---�
. -- --- - - . - North Carolina-. -. :_=
- Department of Env3ronment and Natural R�sources
Division of Watex 9uality
Groundwater Sectlon
P.O. Box 29578 • Raleigh. N.C. 27626-0578
1. WELL LOCATiON: tSho�a ske�h ef the lec�on oa
2. owvER: C�-3 T (.� ►Z.o�..�
3. ADDR�5:
4. 'i'oPOGRA.PHY : c'.taw. slope. hilitop. valley. �at
�� DA'IE'`S =( C� • O f
5. USE OF �'ELL: ,
6. TOT.�L. DEPTH: �G2O. � DIA.ME'I'ER: �'
7. c:.�SING RE.'1�tOVED.
� SS�:
��
��...— -----
8. SEAL:NG MATERIAL:
jY!'3L CeliltllL
bags af cement �._..
gala. of wacer __
i�yp�e materta!
Cane{ remCriL �.
�ags of cemen: �
yds. of ea.zd __
gals. of water _,_„__
�,,mount
9 IAtri METfi�D F1�iPLr�►CEMENT OF I�WTERIAL•
�v 2 � �.� —
k of fozsn.)
Caunty —
fluadraszgle No. _
,I, DLAGRAM: Draw a detailed eketch of.
well shaunsi$ total depth. depsh and dfa-
x of screeas remaiiiing ia the well. $rd►vel
rval. inteivals of casing perforations. and
ths and types of 911 materials u3ed.
I do hereby certify that this �e11 ahandorunazt record !s true a�ad exact•
�•
Signature of Con�actor Agent
C�� Date s.� " �a' U /
VVELL LOCAZION: Draw a lxation sketch on the reverse of tht� sheet. showir$ the 3trec•
hon and distance of the weil t� at :ea9t two l2) nearby ref�encx points
such as roads. iatezsedions aud sueams. Idenrify roads wittt Stat� High
way road identiflcation ncuabers.
Submrt orig(na! te the Divisior_ of Water 9uaI1tY. oae coPY to the Drtilrs.
and nne copy te the awner.
cw-3o ��:�� i �sa
Date:
Owne
Location/Directions:
Fr� � � � C/
PERSON COUNTY ENVIRONMENTAL HEALTH
� WELL LOG
Subdivision Name:
Drilling Contractor:
�
Lot #
WELL CONSTRUC'I'ION �
Distance from Nearest Property Line 1 v Distance from Source of
Pollution ( G o
Total.Dep.th:�__ Ft. Yield: �h GPM Static Water Level U?.r" Ft.
Water Bearing Zones: Depth 1(b�F[. � Ft� Fc. �c.
Casing: Depth: From 6 to��,Ft. Diameter: Inches
TYPE: Steel - Galvanized Steel
If Steel, does owner approve: Y�s No
� Weigh� � Thickness:� '� Height� Above Ground: /�/ Inches
Drive Shoe: Yes ✓ No .
Were Problems Encountered in Setting the Casing? Yes No �
, If "yes" give reason:
Grout: Type: Neat Sand/Cement / Concrete
Annular. Space Width � Inches
Water in Annular Space: Yes No
_ .. Method: Pumped � - Pr�ssure � Poured � � - � � �
Depth: Fr�m O to �. � Ft.
Materials Used: No. Bags Portland Cement Weight of .1 ba� lbs.
If mixtuie (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes � No � � �
� 4 x 4 slab Yes � No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C�ui�ITY HEALTH DEPARTMENT.
�_ � _-
i naturc of Contractor D� tc
Person County Health Department
Environmental Health Section
Tax Map #: � �� Parcel #• '�
Zoning: ^ Township: �����e. H' ��
Subdivision: �s SP� � Section: " Lot: _�_
Appllcant: �is�a� �,� � � � /, .?-� •
Location�/.�� �_o� �i��-_ •
Oper�tion Permi��
System Type (In Accordance With Table Va):
THIS SYSTEM HAS BEEN INSTALLED IN COMPLlANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORiZATION. �
?'�--�� .
Authorized State Agent Date
Tax Map #: Parcel #:
PCHD, rev. 10/12/99
_
Date:
Ownf
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
. t� � ,��
v�
'`1� e�� n
�����ti� � �� `
a ! �� �� ,
V )
SR#
Location%Directions:
Subdivision Name: � Lot # .-��
Drilling Contractor: � � ►��
WELL CONSTRUCTION
Distance from Nearest Properry Line ! v Distance from Source of
Pollution ( G a
Total.Dep.th: O F� Yield: GPM Static Water Level a.5� Ft.
Water Bearing Zones: Depth f�._Ft.�Ft ��� Ft �t.
Casing: Depth: From 6 to��Z Ft. Diameter: Inches
TYPE: Steel - Galvanized Steel
If Steel, does owner approve: Y�s No
� Weight: Thickness:�, '� Height�At�ove Ground: /�i Inches
Drive Shoe: Yes ✓ No .
Were Problems Encountered in Setting the Casing? Yes No �
Grout:
if "yes" give reason;,�, ,�:_.., LQ�1 l,`z'ti�,T .
Type: Neat Sand/Cement / Coricret
Annular Space Width � Inches
Water in Annular Space: Yes No
Method: Pumped � - Pr�ssure � Poured � -
Depth: Fr�m O to �. � Ft.
Materials Used: No. Bags Portland Cement Weight of .1 ba�_lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes � No � �
4 x 4 slab Yes � No
I HEREBY CERTIFY THAT THE ABOVE INFORMr�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY-THE PERSON C�Li�ITY HEALTH DEPARTMENT.
�
_ �
Q �--
Si ature of Contractor < i�
�� �
� y � 1 �
���� � � � � ����
1L..R/�.,�1}��%�.���i�.�'i�.�e�i.� .tl. 1J.�✓`�.�tl.�
Building Additions/ Mobile Home Replacements
Tax Map #:� Parcel#: �� %
Approval Requested for: Mobile Home Replacement
_�Building Addition
Applicant �.
Address:
Phone #'s:
�j�� ��1L��
i�ODi✓�/D� //�Pi .
91� �s o�sa
Permit Located: ✓ Yes No
Installation Date: �-� -D� Design flow: �2(�_ (gpd)
Current Contract with Certified Operator on file (if required): /Vd
Water Supply: ✓Well Public or Community
Wastewater system shows no visual evidence of failure on: (date -/ r,
(Applicant's signature if site visit is not required) GQ�S�G�C.. -�-/l%C,
Addition/lZeplacem�nt Approved
� 27 Q�_
Environmental He h eci Dat
Page 1 of 1
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