A29 17AApplication oate: � �8 w
Amount Paid: �
Receipt #:
Tax Map #:
Parcel #:
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APPLICATiON FOR SEi2VICES
CONST�tUCT SHAL�. BECOME INVALID.
1) Permit requested by: (Ownerlagent/prospective owner): �-�-'��I�i�
Home Phone: Address: o �Q�O
Business Phone: ��,�/r • G
2) Name and address of.current owner:
3) Property Description: Lot size: Township: Subdivision: Lot #
Directions to the property (Including road names and numbers): n� o�,/T3.�,� • ��� __ _
4) Pro�rosed Use and Structure Description: answer each of the foilowing questions:
a) Proposed _, Existing _, Type of Structure: Width: Depth:
b) Number of Bedrooms: _� Number of occupants or people�to be served: 2.
c) Basement: Yes , No �Will there be plumbing in the basement? /y' D
d) Garbage Disposal: Yes _, NoC/—
5) Water Suppiy Type: Private �(new _ or existing�, PublicJ Community_, Spring _
. Are any wells on adjoining property? Yes r/No _ If yes, please indicate approximate location on the
site plan.
6) Does your property contain previously identified jurisdictional wetlands? Yes_ Plo_
PLEASE NOTE THE FOLLOWIiVG:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMiTTED WITH TH1S APPLICATION.
➢ PROPERTY LINES AMD CORNERS MUST BE CLEARLY MARKED.
➢�'HE PROPOSED LOCATION aF ALL STRUCTURES MUST BE STAKED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AiV EVALUATION BY THE HEALTH DEPARTMEiVT
STAFF.
I hereby make applicafion to the Person 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.
Owner or Legal
� � ��a3
Date
PCHD, rev. 06/27/02
,.
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��-�a����m ����..Il J�1L��11-�I�
Tax Map #_���. Parcel # /7�
Existing Sewage System Report For. Mobile Home Replacement
- x Addition Type: �"_>�i-�nir�j
Requester. �D� �• �l:��,� Home Phone# �7� �/D
Z �D ie%t�aoi✓ ��ia1l�t! �a- Business #
,�Pa�r��; �11� 2�.�� �
Location• �
Original Permit Located: Water Supply: Gv�'r,�l.�
Septic System Designed For: �_Residential Business Other
# Bedrooms Z # Employees Other
System Type:�n f�t�� Tank Size: a Nitrification Line: �� �
���' /55��� .
Date Installed: Certified Operator Required:
�c����
On-site wastewater disposal system shows no visual signs of malfunction on '�'�.
Permission is granted
Coniments•
�
Environmental Health Specialis Date:
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SITE ST{ETCH
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Subdivisi n ` � � � , if,N ,�. Section/Lot#
�. �
Authoiizec� Agent Date
\
Syste»a co�aponents represent a�'iproxi�nate contours only. The contractor �nust,flag t/ie systemps-ior to
begi�zning tlae i�istallation to insure tlzat�iropergrade is t�zaintai�ied
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' Yerson Councy Health Department
�xisting Sewage System Report Eor: Hobile Home Replacement
�Addition��rf�.S�i.��a� _ ._
/
Requestee: �O�P�'/ `, �C�� Iiome Phone# 597.�/��
a�D �✓e�a�or� ���^��r� /� Business;
1!"�� X�D/'D �/,"i/C� �%S � 3 '� ax M a p� �
Location/Uirections:. ��cS �o ��rs.S��-e%!�'�%, l��v; �,.►
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. u i ez-� r v-�r_ �
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Original Permit Located ✓ '
Septic System designed �or: _ _
Kesidential � f3usiness Other {specify}
� Sedrooms " # �mployees ^ Other �
Uate Installed 2"%S% Water supply P�,�u %�-'s��%-�-�
�--
Type ot 5ystem ���,✓- /�D � X' �� W�TI ����f ��a-1 Qs�
Nitrificatian Line /l0'X� �
Tank 5ize /SUga
Certified Ogerator Required �D �
, On site wastewater disposal system showes no visual.Zy apparent
malfunction on /D -- �- O/
Yermission is granted to: �r. ���/ �Dn�Shh�p J`�D �X� �
Accordinq to the attached site pl.an.
Comments: �2e /2oY�S Oh �����/h�/ta S/1r�/ //qTTG�-�l-��
Environmental Health �pi�C..
s�
DATE
�e�niic�tion .Oa-te: ! %2 7 � �
;�a�nc�rai aaim-� �—�G •�-+��-
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� "� " � �Z"".. :.c : � . �srsore� Cacar�#v �?ea�th �3emartm�nt
�;� . . . �. .. . ...._. .:: ;fsvicr3nr¢;�r�I Health Sec3ion
T��: i4�a� � �� !
;3?pz�i .T � 7%`�—
. �:.: . . _ . ._._ . .. ,. . _�:
� � . . . ;•: ";:. AP�L'lCAT10N i'-0R SEitVICE3 •
IF THE INF-0RMATiON tN THE APPUCATtON FOR AN IMPROVE3AE�1'T PE�tMIT IS FALSiF9ED, C9�lANGm, OR Ti�IE S1TE 1S
ALTEi�E�. THEiN THE IAAPROVE�AE�1T PEiiM1T AND AUT'HORfZATlR]A1 TO CaPISTRUCT SHALL 8E�L7ME 1NVALID.
: ,�o3£�r- C'_ Ac,�R /��►- p- AcX�a
�, . Hocr�ie �or,��'�- So oe�tag.��eee�e ou �d�: 2 s� o��F ��� N wrC�,�N Ro.
8uetitE98 PhOnB: � �Pna'l�.olL^� NC a�75h 3 .
2� Name actd addce� �of c�rnertt owner: �3�.,a; �!E�`_' ��► JQC�_.2_ •
. �� .o w� ��,� wu ��✓ �-
• '�`0 ��i,olLo' �N C '•Z 7 5�7�
• .93 �c�� ^ � •
3) Property Descriptton: l.ot s�s: �� Tawnsi� •
,; Dlredtons to the P�I�Y (Indu�irt� road �names and numbers): � w y � 9 Sa u n�
4) Prvpos�d llse and Structtare �esari�ftlon: answer each of the foUowing questtons:
a) Propcsed 4 Ex�ing ❑ ' � .
b) Sgdc Bult q Modular Q Stngle Wtde �. Double 1Mde a • �
c) Numher af Bedrooms: • d) Nucnber af cccupar�ts ar peoQle to be sesved
� �). ..Basemerr� : Y�es� Q Na'�tf yes, #�af basemecrt fnd�ues: . . . : . . . .. . �.. _ .. _ - - . - ..
r% � �GO�4�. D�� "7 �. u' ii� L1 ""'_ . _•-.....� .. » .. ..-.. v : .� �' '- ' • ' ^ r1 J � .. ... . � .
� �imensions of Propoaed Struc�: Width:.so Depth: 30 �� �Jo r 1�S� ��
� Wa�r Su}�ply Type:. Private 0(new � or exis�n9 �, Pubi6c q Cammunity q Spring ❑
. �• Are acry wel4s on a�omin9 P�Petty? Yes ❑ No Q if yes, loc�tton �
s) Piease Indicatia D�sired System Type: (sysi�t�s can he ranked in order of yo�u prefei+enc�)
Canve�ot�l _Adc�l9ed Canverrtlonai �Alternativ�e. Inno�ative
Qther (speciiyj: .
CL�.�RLY STAKE ALi, CORNQiS AN� L1NE3 OF THE PROPEit'iY.
STAKE THE CaR1VEi�S OF ALI. PROPOSED STRUCTUR�.
PLE�►SE ATTACN SURVEY P�.AT OR 81'TE Pl.AN TO THl3 APPL1CATiON
.�
1 heteby make apQlication to the Petson Caw�ty Healthh De�artment for a siie e+raktation iar the on-site sewage dispasai system far
the above-d��ed proQerty. i agree that the cairter�ts cf this applicatian are true and nepreser�t'the ma�arn�ua fadGties tc be
piacad on the praperiy. I understand if tt�e siie ls aite�ed or the i�endect usa ct�anges, the permit shall b�ame im►ei[d. 1 understand
that as applic�nt, ! am responsibie for ider�ifying snd mar�ng properiy I'�nes, camess and malcing th� siie ac�sscbie fa' tt�e
personnei of the Pe�san Cawriy Health Departrnerrt to canduct their eval�safions. l understand that I am respons�ble for notiiying the
Heatth D artrnent ii my pr�o rty cantains any wetlat�ds as desigr�ated by the ,4rmy Carps af Ertgine�rs.
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0 or Legal REpresentative . Qate �
pCHQ, rev.10M2199
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CONTROL
CORNER
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Per.
� ��a
No.`
Septic Lanit and niti
a' aiembez oi ihe i H�
installalion is `cov+e�c+
Date � Approved �, . `
..
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Applicant:
Location:
c.
/ /
T�x M��� � P�,rcel # �
S�eihcllivi�s�ion
Ph�•s�e Section Lot #
Improvement Permit
Permit Valid for �' F've Years No Ezpiration �fFlq� �
Type ofFacility: v� New Addit�on ✓ Water Supply-��
# of Occupants # of Bedrooms _-�� Projected Daily Flow � g.p.d.
Proposed Wastewater System: Type:
Proposed Repair: , N/✓d �/��i✓� Type:
Permit Conditions: �i�ow � l.i .�,lC�1��' � ��,L��4a�z�� � : _
L� r� ���
Owner or Legal Representative Si ture:�'' ` Date: �—T "� 6^ a3
Authorized State Agent: � Date:
The issuance of this permit by the Health Department i oes not guarantee the issuance of other permits. It is the responsibility of the
applicant/property 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 ownerslup of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rules for Sewage Treatment and Disposal Systems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warrants that the septic tank system will continue to fwnction 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: %n/�cc���-G Type � Wastewater Flow s�g.p.d.
New Repair�C Expansion _ Soil � • ZS� g.p.d./ ft 2
Type of Facility: ���� Basement _ Yes � No
�������� Wastewater System Requirements
Tank Size: Septic Tank: 7� gal Pump Tank: _�_ g�� �l�/b� Grease Trap: gal
Drainfield: Tota1 Area: � sq $ Total Length ���t Ma unum Trench Depth �fv in
Trench Width � ft Minimum Soil Cover: �_ in Minimum Trench Separation: 9 ft
�Distribution: Distribution Box �_ Serial Distribution Pressure Manifold
Authorized State Agent: �
Permit Expiration Date:
Date: .� d �
The type of system permitted is Conventional � Innovative Alternative. I accept the specifications of
the permit.
Owner/Lega1 Itepresentative: Date: �� o ���
PCHD7/30/2002
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SITE SI�ETCH
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Name �'• i�e� Tax Map #-�� Paxcel #�
Subdivisi n � D �/ ,�p. Section/Lot#
o�
Authorized Agent Date
Syste»z components represent approxi�nate contours only. The contmctor �nustflag the system p�-ior to
beginning tlze iristallatio�a to insure that�iropergrade is maintained
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Applican
Location
T�x M�p � � F�rc�el � !
S�ubd!ivis�ian
Phas�e SecMtior� Lot �
Operation Perr�it
System Type (In Accordance With Table Va): ��
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NQRTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF T}iE IMPROVEMENT PERMIT AND. CONSTRUCTION
AUTHORIZATION.
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Authorized Stat Agent Date
Installed B: ., .S rr..�� Date: �- D 3
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S��'i1C YANK INSPE�TION CHE�KLIST (Type 11- IV)
. Tax Ma� # Parce! # System Type (Tabie Va) �
Owner/Applicant Subdivision
Address/Location SeclPhase Lot #
Seatic Tank n� a a e itn cat�on ines n�t�a atp
State ID/date
Capaciiy.
Tee and Filter .
Baffle
5ealant �
Riser (if applicabie)
Tank Outlet�.Seal
Permanent Marker
Pump Tank
Waterproof /Sealant
Riser
Pump
3ate Valve
Floats/Switches � �
Alarm (visabie and audible)
Electrical Components
Rate (gpm)
Approved Pump Modei
Blocic Under Pump
Pump Removal Rope/Chain
Distribution System
Serial Distribution '
ressure an o
Low Pressure Pipe •
Appr. Pipe Materiai and Grade
Trench Width , ft.
Trench. Depth in.
Trench Length ft.
Trench Grade
Trench Spacina
Rocic Depth and Quality
Dams/Stepdowns etc.
Pressure Laterals
Hole Spacing .
o e ize
Pipe Sleeve
Tum-ups/Protectars
Required Setbacks
From Welis �: .
From Properlv lines
� uitcnes iurainage ti
-- . - . . � . Surface Waters
Public Water Suppl.
• Vertical Cuts >2 ft.
Water Lines
Vehicle Traffic
Easements/Right of W�
Other
Easements Recorded .
ert e perator oni
Tri-Partate Aqreement
Cominents
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rovements Permit (Established/Recorded Lot) I_ Reinspection of Existing System (Loan Closing)
Improvements Permit (Unrecorded Lot)
ts Permit (Mobile Home Replace)
mprovements Permit (Addition)
Repair/Replace existing Septic System
Permit for New Well
ace Existing Well
Bacteria Chemical I _ Petroleum I _ Pesticide I _ Lead
'ermit requested by: Robert C. Acker 7• Dimensions or Proposed Structure: �
ier rospective owner/agent: Width: 2 4 f t. p e� �� e �
lress: 240 Weldon Wrenn Rd Depth: �R �t Garage
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 #: 91 0-597-51 1 0
usiness Phone #: 91 9- 5 6 0- 4 2 81
. Name and address of current owner: 9. Water supply type:
Same As Above private C� public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No ❑
If so, identify location:
Description: Lot size: . 93 acres _
. Tax Map##: A- 2 9
Parcel#: Lot 1 7-A ( DB 1 86 pa 587 )
Township: Olive �Hi�l
. Directions to property: State Road #& Road
Tames, etc.
� _ .. __�.. .,, .• ---- �---�----- L---
Wrenn Rd. to the left 3rd house R/S
. Number of occupants or people to be served: �_
10. Type of structurelfacility: Proposed: ClExisting:�
Type of dwelling:
House: � Mobile Home: ❑ Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: 2
Garbage Disposal? Yes ❑ No C�
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 Pet'sOn COUIIty 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 Heal[h Dept., this application shall become void and all fees paid forfei[ed.
��,��' G��
Signed Owner or Authorized Agent
, • . ,
permit Issued ❑ Signature
Permit Denied ❑
Plat Observed ❑
Date
s .� , FACI'ORS-STlE £\!XLQA770N „`` . " : .: < s , r ` . AAELS 1, .. ;: ;' ARF.A 2. ; % > �f ' ARF.A 3 ; i�A 4 >s.
_ .>...:�... . _._
1 SIAPE (9F) S S S S
' PS PS PS PS
. U U � �
2. SOIL.7FJ:7URE(12•36INJ S S S S
(SANDY. LOAMY. CLAYEY. NOTE 2:1 CLAY) PS PS . PS PS
U U U U
3. SOIL S7RUCNRE (12-36 iN.) S S ' S S
(MYEY SOILS) � � � �
U U U U
S S S S
J. SOtI. DEPTH (IN.) PS PS PS PS
V U � U
S. RESTRICCIVEHOR[ZONS(INJ
S S S S
(IMPERVIOUSSTRATA.ROCK) PS � � �
U U V U
6. SOII. DFWNAGFIGROUNDWATER � S S S 5
(EXTERNALg W7ERNA1.) PS PS PS PS
' U U U U
7. SOQ. PERMEABILiiY S S S S
(PERCOLOATION RATE) PS � � PS
U U U U
S S S S
8. AVAILABLESPACE PS PS PS PS
U U U U
9. SiTECLASS[FlCATION(SEEBELOV,�
SOIL SERIES
SSUITABLE PS-PROVISIONALLYSUIiABLE U-UNSUiTABI.E
RECOMMEN DATIONS/COMMENTS :
STTE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.� C:WMiPR01DOCSAPpSEC.SMFlNANCE.PC
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• PERSON COUNTY HEALTH DEPARTMENT . �
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT
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 been issued.
Tax Map # � % Parcel #
Zoning Townshi
Owner/Contractor C�
Location/Address � R S� l l/,
Subdivision Name
SFD
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Date =� :,,�_ 9�
/ l L. �/ �1 �/�u P p,-� r/
S.R.#�� `
Lot#
SEWAGE SYSTEM SPECIFICATIONS
Lot Area ��, �.1 �i c•� Size of Tank
Mobile Home Size of Pump Tank �, j�
# of Bedrooms Nitrification Line �,1�, ���i�p
;, .� �� p,( ��,�� Max Depth Trenches �
Permits may be voided if site is
Well and Septic Layout by
Comments:
Date �- 3-GI� Installed by /(Q � �1 S�1PG�?.=L, Approved by
Well Permit Paid ❑ WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab
Public Re Air Vent
Site Approv Required W og
Wel ad Approved Well T
Grouting Approved
Comments:
Date
This report is based in part on infordlation 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 ia the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
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PERSO Ul�TY HEAL�H � �PARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Map # � Parcel #
."
ng Township __ _
Owner/Contractor
Location/Address_
Subdivision Name Lot#.
�n� �
S.R.#
5EWAGE SYSTEM SPECIFICATIONS
Repair Lot Area�; �i � u,� ��S Size of Tank
SFD Mobile Home Size of Pump Tank
Business # of Bedrooms Nitrification Line g �'�'�, �;
Max Depth Trenches
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is t�rey� or 'nte ed use changed.
Well:� by �� '
Comments: 1'0`�'° �
Installed by
by,
Well Permit Paid I� WELL SYSTEM SPECIFICATIONS
Individual_�_Semi-Public Required Slab `'
Public Replacement Air Vent "'
Site Approved - i/� Required Well Log `�-
Well Head Appr evo d � Well Tag ✓
Grouting Approved � '
Comments:
Installed by � ��A'i�7 � Approved by.
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this perniit. The
environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health
specialist is also no[ 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 wacrants that the septic
tank system wi11 continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro\permit.sam 01/95 rev.1.0
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Date: � �
Owner:
Location/Directions:
��b�':vision Nv11c:
Drilling Contractor:
PERSON COUNTY �NVIRONM�NTAL H�ALTH
W�LL LOG.
_ „_
SR# � � � r
Lot #
WELL CONSTRUCI'IdN
Distance from Neares[ Pro�:r�y Luic�.�(� llistance from Source of �
Pollution o d ) ws '
Total Dep.th:_ /� v Ft. Yield: GPM Static Water Level 2 Ft.
Water Bearing Zones: Depth �� . Ft. � F� Ft. �t.
Casing: Depth: From 0' to ,� Ft. Diameter: G� Inches
TYP�: Steel � Galvanized Steel .�
If Steel, does owncr approve: Yes No
� Weight: /3 Thickness: �_��eight Above Ground: /� Inches
Driv e S ho e: Yes �No =
Were Problems Encountered in Setting the Casing? Yes No �
Ii "yes" give reason:
Grout: Type: Neat Sand/Cement � Concrete �
Annular. Space Width 3 Inches
Water in Annular Space: Yes No L�-
Method: Pumped Pressure Pot.reci .,�--
Depth: Fr�m �—to �_r t. - �
Materials Used: No. Bags Portland Cement�_ Weight of .1 bag�lbs.
If mixture (sand, gravel, cuttings) - Ratio: � to 1
�ID Plates: Yes c� No � � � �
� 4 x 4 slab Yes � No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITN REGULATIONS �SET
FORTH �3Y�THE PERSON COUNTX HEALTH DEPARTMENT.
���- t.�� � � , �
Signature of C,ontractor Date
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