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A29 186• ;��idlication Date: 3 -� � °a � Amount Paid: � Oa Receipt #: ��� • � -�s'7o6 J' a Tax Map #: /� °2 I Parcel #• � � G Perso� CountY Heaith Department Environmental Health Section . APPLICATION FaR SERVICES � IF THE INFORMATiON IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED. CHANGED. OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVAUD. 1) Permitrequestedby: (OwnerlagenUprospectiveowner): fi�►'�+�en� �a-r/�` 5- Home Phone: L,�`l-5l� �— �/7'� Address: o I.�l. �^ :� . Business Phone: 9/4• 3cW—zzzfy t�i, �, vr �• � y'�c� 2) 3) Name and address of current owner. �/in,e� l7�'.`S- �d� Lt�� C'y��ztias... �. vr,�$C.i.h.e�,j�r � Z7�cZ ���� Property Description: �ot size: � ` Township: ,{ �. • `d %11 Oirections to the property (including road names and numbers): �f s• • �... ��� � 4) Proposed Use and Structure Description: answer each ofthe following questions: a) Proposed l9!Existing � b) Stick Built �, Modular �ingle Wde �, Double Wide U� c) Number of Bedrooms: �, � Number of oa:upants or people to be served: e) Basement: Yes 0. No �tiyes, # of basement fixtures: � Garbage Disposal: Yes 0, No T�--' g) Dimensions of Proposed SUvcture: Width: ,� Depth: �a 5� Water Supply Type: Private49'(new � or existing �), Pubiic q Commun"rty �, Spring ❑ Are any wells on adjoining property? Yes D No �if'yes, IocaGon 6) Ptease Indicate Desired System Type: (systems can be renked in order of your preference) �/Conventional Modified Conventional _ Altemative Innovative Other (specify): CLEARLY STAKE ALL CORNERS AND LlNES OF THE PROPERTY. STAKE THE CORNERS OF ALL PROPOSED STRUCTURES. PLEASE ATTACN SURVEY PLAT OR SRE PLAN TO THIS APPUCA7iON I he�eby make application 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 faaGties to be placed on the property. 1 understand if the site is altered or the irttended use changes, the permit shall become invalid. l understand that as applicant. I am �esponsible for identifying and marking property lines, comers and making the site accessibte fo� the personnel of the Person Caunty Health Department to condud their evaluations. l understand that 1 am respansible for notifying the Heaith Departrnent if my property contains any wetlands as designated by the Army Corps of Engineecs. ��.-,�.,� /' ��-u-� 3 % Sl ^ O� Owner o� Legal Rep�esentative Date . PCND, rev. 10/1219 Tax Map �: ��_ ParcN # 1 g� To+rur►ship I��f V t�� �1 PIN � Appiicat� t v G�V i 5' S,ubrdivislon �Se V�(�t C i rc� e. Phase/8ectlon LottF � Locat�on: '��S e5'�e�5 ,S el� �d �Q/i�er Lpo Imvrovement P�rmit New '� Additio� � Type of SVucture 3. ��- �'S ��en�u- ( Water Supply W� �� . # of Occupants # of Bedrooms Projected Daily Fiow � g.p.d.p Proposed Wastewater System: _� � Proposed Repair. �uw. c� ; hv Other System Type iit Valid For. Five Years 4 No Expiration nnV2U��'� or�w, � � , t_ PermitConditions: eP Suua�� ��ne 5� �row. nro�y���y���+n�_��ccyG� 54STew� lh� �� ,� - - � �, � , , � _ � �� �, � n �_ •� ►, n ��,-� -r. _, u _� . _ c The issuance of this permit by the Health De�artment in no way guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate goveming bodies in meeting their requirements. This site is subject to revocation if the site pian, plat, or the intended use changes. The Improvement Permit shall not be afPected by a change in ownership of the site. This permit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatment and Disposal Systems oi'the North Carolina Administrative Code. . Authorization To Constrv�Y Wastewater Svstem tRea�i�eci for Buildinq Permit) WastewaterSystemDesCription:�w�^p l4�hvzv� ie�� WastewaterFlow: �b� a.p.d. Type�ti- Facility Description: .3 BY- �S f���` �� Nev� Repair ❑ Expansion a Basement? O Yes No Basement F'ixtures? � Yes No Wastewater Svstem Repuirements Tankage: Septic Tank size GbD gal. Pump Tank size l ooa gal. Grease Trap size /1� �i' gal. Trenches: Total length yUb ft. Trench Width 3 ft. Total Area f ad0 sq. ft. Max. Trench Depth: � in. Aggregate Depth:_„��, in. Soii Cover, � in. Trench Separation ,�ft. on center Perrnit Expiration Date: 7�a 7' p� , Authorized State Agent Date: ^ � '�`' *See attached slte plan and addendum pages for additional permit conditions. , The type of system permitted ❑ daes ❑ does not differ from the type specified on the application. 1 accept the specifications of this pertnit OwnedLegal Represer�tative Signature: _ZS" " �� . Date: � —..� 4 —� � Operation Permit System Type rn acxordance with Tabfe Va) � This system has 6een installed in compliance with applicable idorth Caroli� (3eneral Statutes, Laws and Rules for Sewage Treatrnent and Disposal, and all condidons of ihe Improvemerrt Permit and Construciion Autlwrization. lssuance of this permit implies no guara�rtee that ths sysbem instatl�d will iunction properiy for any givea period of time. Authodzed State Agent Date , PCHD, rev. 03/07/01 . . , • •, � � ' ' Appllcatlon #: � � � . . . Tax M�p #: � ��. . � P�rael t�: �� Person County Heplth Departmerlt . � Environmentai Health 8ec�lon , � � .. � � � � 81jE SKETCH , . ; ' � �� d / �IJ6c ✓rs i � !e (,r � � � � � � �_ . pllaant'e Name • � 8ubdivlelon/8e tfonil.o!# ,-a �o . Authorized 8tate ent Date , � � � Sylism com�ponenla t�spreaent appraxlmats conJot�r� on�y. Ths coatrnctor niaat flag fhs rysleaa . rJor M b inn thelnatallritlon to ln.tWre rtliat ro er '�a malnt ned. , �� �e st� ,p `v1 l l�.'� � l�YD►� 5 �1 y�y-� b�i ac�. � P �.� I ' �'� P`��er`�"�' `�-w.�,-� � � �foa k �� ' � _v . . ��10 � s��fi,'� �.�. -� ,o �, i�u,�p c�r�e�;�,.�.. � �C,e, a-s �,,. (� 1�; h as �,���`- S�� t-��., . { ( $ �M.ci�c. 't'tQ�.a� %� ' � ���ss �ble � � a��� I • �novu�;�� ��P se��c S�( S IC (�v�, l a w� 1 n. ��,p.�; r � . � V -��� ���e�-fiy (��.� � . � � . .. � Se�- 52P fi c. �' �v"`�„`� ��S �,� �o� ��. � .=�►�.. (�..; l�; , --�'`�p �►�x� vv�.�,�c, i� wst S; 4e � -- w e.l I . A-�- � . � � 5'� `�' c. Q� �,"ti -� r„ � �a� , �� � � P � �( � o' -� w• ��y � �,.� , . ___.... �` �.0► � soa�e: ! = ........ ___. w n�a �f�n0 . 9 � � . � . - . . � ��S�N Ct�l9N'�'� �iR�N�AE�iT','�l.. HE�T�i ' . . �i�,c� �� ��i'�+GNEi3 P��N K�R ��. Sii'E i,�`f�US . . � ��� � �a� � �# i�� . - . .. � ��i � � - _� . , � (•yter v cs - � , . ��oa:ms . � . � �-un. v � . � _ � a.�,.,.., _ . ' �C7f �� • . _ T1/Qe Of �li�Bf Sil1]O�l/: � ��� • PU�7�C .... . , ' . . . , • . ReOUiiBfnAi1�5: . sitie APQ� bY � �'S �r � -o/ ' . . ' - G �g ,qQN�„�a�red by � - - o � . :C� - VYe� T ' � � Air Vent • . . Hase B� . Concxete Siab � Vliell Dtilfer' � , lAlell Approved By: �� �i���C - *''Ses k�� Stts S��rh" ' We�s must be 10 feet from , proQett.Y lines- � � VYe�s must be 100 %et from se�tic sys�• ,". �� � � Weils must be at l�st 25 ieet frotn arEy. bw'ldm9 foundation. . Other cortditions: � . PCti�. re+r. 111Z� PERSON COUNTY ENVIRONMENTAL HEALTH WELL LOG . • . Date: L ' Owner. h� � �`@1 ����-r�, � SR# ' � � Location/Directions: � � � Subdivision �Name: __ c����.—r� � C . Lot #�_�_ Drilling Contractor: � � �� WELL CONSTRUCTION Distance from Nearest Property Line 1 v Distance from Source of Pollution t G o Total.Depth: Ft. Yield: S GPM Static Water Level a2.5—' Ft. Water Bearing Zones: Depth �.._Ft.B�F� Ft� Ft. Casing: Depth: From 6 to�g_Ft. Diameter: Inches TYPE: Steel � Galvanized Steel If Steel, does owner approve: Y�s No � Weight: Thickness:� '� Height�Above Ground: I�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 / Coricrete Annular Space Width � Inches Water in Aiuiular Space: Yes No _ .. Method: Pumped � - Pr�ssure � Poured � � - � � � Depth: From 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 � No I HEREBY CERTIFY THA'� THE ABOVE INFORM�TION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY�THE PERSON C�ui�ITY HEALTH DEPARTMENT. � gnacurc of Contractor < «� . . ��ascn ���a�iy �3�ait4� �3eQat�dmersi � 2� � �.�vsr�nrner�tad �3� �Secfion : �� � �'ax�� Z�ning: . Towns�hiQ: n �►V'�- G�'`� � .. Subdhrisio� _�64P [N �� l � YC � Sedton: _.____ La� � �� � � � ��: f �;t' � � � - . . � e�rati on P�e�m it -, �' System Type (In Acca�danc� Wiih Tabie Va): , b _ THIS SYSTE�II HAS BE�iV INSTALLEfl tN GONIPtJANC� WCIi�1 AP�UCABLE NORTH� CAR�LlNA GF3+lE3iAL STATUTES, RULES FaR SEINAGE TREATNE�+1T AND DISPOSAL, -ANQ �ALL CtJNDtT1�NS OF THE IMPROVE�AEiNi' PEiiNI1T �AND C�NSTRUCTION AUTHO ON. � � � . �� � � � � '��'� l or¢ea srate Agent � � D�e g �' � °�1�� �� `�'"� P� �a�' pT�- �� . . ST � 1 �Z � l'�.-a ( � . �3� ` �-� �`` P�� s�'P�� �'�� . �� PERSON COUNTY HEALTH DEPARTMENT SUBSURFACE WASTEWATER SYSTEM MONITORING REPORT � � 3 S l 3� /aoo ( �� l� Dat of spection System Installation Date Type TaxMap Parcel # 5 '7 �/►'Ue.- �od� �� Property Address Instructions: Check yes or no for appropriate items and explain inspace provided for remazks and comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate by "N" and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance and monitoring items specified in the permit are to be carried out. INSPECTION RESULTS COLLECTION SYSTEM: Evidence of leaks ? Tank risers accessible, free of infiltration and surface water diverted ? Septic tank needs pump�ng ? �nches �f solids: 1 �" � Septic tank filter cleaned ? FFFI.UENT DOSING SYSTEM: Required pumps present & functional ? High water alarm operating properly ? Floats, valves, etc. in good condition ? Control panel & components in good condition ? Effluent &ee of excess solids ? �� Inches of sbiids(pump/dose tank): 2 Elapsed time readings 7 IilS� Counter readings ? Vl °I Drawdown rate: • ■ '►-: ►': ■ �� ■ � ►: ■ � �� — ■ : ■ i ►i ■ ►� ■ DISPOSAL FIELD: Evidence of effluent surfacing 7 ❑ Evidence of effluent ponding in trenches ?❑ Surface water effectively diverted ? Diti�eLS!QIIS/S`NBIPS *�LO'�S?'ly ?1131nt21II?� i Vegetative cover maintained 7 Pratected from irafiic/unauthurizzd uses ? Distribution devices in good condition 7 Field free of settled or low areas ? ► ►� ■ ■ �. ■ ■ REMARKS � ����fvt.�- `��r' �.Je�s ����/ C����, � '� �,�K t,��e,�s �' �-e. � � ��� o�� � 2���t-��.� ��� 1�� �-e� t--��Zccc,-eoQ W l S �(r� }� c� °'�� � �' /R'rr� �'( o� c�re.� � �-e�e,� �` _�� ��Q � � � / �� S CoM✓t �'cL.'t'�sv� 'r �i � at�wt �t,�,����,`u�oc i � Y-.�� �c� � �ea.( i h ���2� �' � K � j vt S� l� S cr-P,�.� r)✓► �`� �- r 5.2�' � �/-2� e�'�*'d�t vv�k.r-- C�.Yo�l n��(9� t` S Yjc�c��y U��ra�,✓� � � ov��-�..� ���.f- i��,-� ;�( ��-�,� � � �tK s C (A '� �}v i��V.i �n�� -P.� �9-r u�l�2.r' ,►?_��� vc-P . � —' J PRESSURE DISTRIBUTION SYSTEM: Tumups/cleanouts/valves/taps intact & accessible ? � � � u� b s C�Q,� ��,� ..� �,�; � e d�� � �� ''�'� Pressure head properly adjusted ? ❑�❑ nq � COMPLIANCE: Compliant ❑ Non-compliant � Needs Maintenance ------ - LII7�,.D �'n. 1•.- �C�,.. /l' ���a.,,_ � o nf r9 C.�T.