A29 190A�plication Date: 3 y) �- 00
A�ount Paid: 1 0.00
Receipt #• ��— . C � q �d .
� 3 766
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Tax Map #- �4 a 9
Parcel #: I 9 0
Person CountY Health Department
��,�� �'' �.� Environmental Heaith Section
g� � �°''�' APPUCATION FOR SERVICES
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IF THE INFORMATION IN THE APPLlCAT10N FOR AN IMPROVEMENT PERMIT IS FALSIFIED, CHANGED. OR THE SITE IS
ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHAL� BECOME INVAUD.
1) Permit requested by: (Ownerlagentlprospective owne�): E%��+ ���� `�-
Home Phone: �)1`l-.SG� �- �/7'� Address: o LrJ. " �^ ,. �-� �
Business Phone: �/�• 3c�-z�zfq fir� � cL.� �, v�_� � r� 7�c�
2) Name and address of cuRent owner. t�i/ir►-ev� p�'�"�-
.3�� Lt�• C���ti,c�s.., �.
� vh �!� c'.;..,.e f„Hj r • �'7 � : _Z
8 '�
3) Propetty Descriptiom Lot size: �'°� Township: ;�e d% 11
Directions to the propectv (Includinq road names and numbers): �f"� s•
4)
• �.,
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Proposed Use and Structure Description: answer ead� of the following questions:
a) Proposed l9�Existing 0 ,
b) Stick Built 0, Modular �ingle Wide 0, Double Wide �
c) Number of Bedrooms: �'�- d) Number of occupants or people to be served: �/��
e) Basement: Yes 0. No 8'tfyes, # of basement fixtures:
fl Garbage Disposai: Yes 0, No C�
g) Oimensions of Proposed�Struy�ture: Width: � Depth: ��
_��
Water Supply Type: Private+6'(new � or existing �), Public Q Commun'�ty �, Spring ❑
Are a�y welis on adjoining property? Yes � No �-tf'yes, location
6) Please indicate Desired System Type: (systems can be ranked in order of your preference)
L%Conventional Modified Conventional _ Aitemative innovative
Other (specify):
CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SRE PLAN TO THIS APPLICATiON
>a-�`-� �
I hereby make appiication to the Person County Heaith Department far a site evaluation for the on-site sewage disposal system for
the above-described property. i agres that the contents of this application are true and represent the maximum faalities to be
placed on the property. I understand if the site is altered or the intended use ctianges, the pertnit shaU become invalid. I understand
that as applicant, I am responsible for identifying and ma�icing properiy. lines, comers and making the site accessible for the
personnel of the Person County Health Department to condud thei� evaluations. l understand that i am respansible for nofifying the
Health Department if my property co�tains any weUands as designated by the Army Corps of Engineers.
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Owner or Legat Representative Date
.
PCHD, rev. 10/12199
' PLEA:
Tax Map #:
Zoning _
Applicant:
Location: _
. / i' %[%/
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se�uo�•
Improvement Permit
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�ot: 2-
A puUd�n ermii cannvi pe �ssuea w���� ���� a�� ���� �� `�
New✓ Repair_ Addition_ Type of Structure�Qj.'� Water Supply��,
# of Occupants %� # of Bedrooms � Other -
Basement? j/]�_ Basement Fixtures? ��
Projected Daily Flow: � g.p.d. Permit Valid For: C�ive Years ❑ No Expiration
Proposed Wastewater System Ty e:�.�11/) I���Ta I fn�l �/�.��G�iU�� � �
Pump Required? Yes �No U
Permit Conditions:
0
rr��L���.
, . _ . Date: S- l Z oZb�
Owner or Legal Representative Signature: /
Authorized State Agent• � • d Date: 5��– ���_—
The issuance of this permit by the Healfh Department in no way guarantees the issuance of other permits. The permit
holder is responsible for checking with appropriate goveming bodies in mee6ng their requirements. This site is
subject to revocation if the site plan, plat, or the intended use changes. The Improvement Permit shall not be
affected by a change in ownership of the site. This permit is subject to compliance wifh the provisions of the
Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code.
Authorization To Construct Wastewater Svstem (Required for Buildina Permit)
f Wastewater System Wastewater Flow: g.p.d. /
Facility Type. New 0 Repair DExpansion 0
Basement? 0 Ye 0 No Basernent Fixtures? 0 Yes 0 No
Septic Tank Size: ga Pump Tank Size: 9a��
Total Trench Length: feet Maxi Trench Depth: mches Aggregate Depth:_, in.
Maximum Soil Cover: inches Trench Separ ' n: Feet on Center
Other:
Permit Expiration Date:
Authorized State Agent:
Date:
The type of system mitted O does Q does not differ from the type specified on
the specificatio f this permit.
Representative Signature:
Date:
. I accept
?CHD, rev/10/12/99
l���S��9 ��3l3iVl� ��R�IIRC�N�IlE�9�'raL l;E,�,L�-9
7ax Map #: /�z� Parc21 #t ,l Qo Township
AppuCan� �{I /2�o v �
L«�non: li' �'S —
PIN
f�7,i Phase/Sectfon
�1,�,.v,r 1�,�,�,�-
lm�rovement Permit.
Addition Type of Strudure Water Supply
# of Occuparrts��
Projected Daiiy Fiow _
Proposed Wastewater
Proposed Repair.
Permit
# of Bedrooms Other
, g.p.d. Permit Valid For. 0 Five Years ❑ No Expiration ,
Owner or Legal Representative
Authorized State Agent:
Date:
The issuance of this pe ' the Health Department in no way guarantees the issuance of other p 'ts. The permit hoider is
responsible for ng with appropriate goveming bodies in meeting their requirements. This site is su ' to revocation if
the site p( t, or the irrtended use changes. The Improvemerrt Permit shall not be affected by a chang ' ownership
of th e. This permit is subject to complianc� with the provisions of the Laws and Rules far Sewage Trea and
' posal Systems of ihe IVorlfi Carolina Administrative Code.
Wastewa#er System Description: ���1 oYr'4�ia.��� �S�� /1e��u��� Wastewater Flow: 0 ,p.d. Type: �
Facility Description: �'B/� �.�%�-°i� ��?!vt i�y �i� New O Repair ❑ Expansion ❑
Basement? 0 Yes"C�1� asement Fixt s? 0 Yes �'1�
lNastewater Svstem Requirements
Tankage: Septic Tank size, f�o gal. Pump Tank size '—' gal. Grease Trap size ' gal.
Trenches: Total length � ft. Trench Width 3 ft. Total Area ��U sq. ft.
Max. Trench Depth: �_ in. Aggregate Depth:�_ in. Soil Cover. � in. Trench Separation �ft. on center
Permit Expiration Date: .S-/�- O�
Authorized State Agent � ��S Date: /�'- 7 O/
�See attached site plan and addendum pages for additiortal pertnit conditions.
The iype of system permitted � does 0 does not differ ft�om the type spec�ed on the application. t acc�pt the
specifications of this permit
OwnerlLegal Represerttative Signature: i��1�� Date• `�'' /O � d/
t��eration Penroit
System Type (in accordance with Table Va)
This system has been inshalled in compliance with appiicable North Carolma General Stah�bes, Laws and Rules for Searage Treatrne�rt
and Dispasal, and all conditians of the Improvement Permit and Construction Authorization. Issuance of this permit implies no
guaraMee �at the sysbem i�stalled wi0 functton properly for any given period of tune.
Authorized State Agent Date _
_ PCND, rev. 03/07/01
Appifcation #: , ,
Tax Map #:
Parcel #:
Person County Health Department
Environmental Health Section
SITE SKETCH
��f� f�u��s R�xUrl (� �rrcle l�f 2
Appiicant's Name Subdivision/Section/Lot#
� �fi�� I�i �, ���.��.��?� � - I i'f�o
thorized State gent Date
System components represent approximate contours only. T/ie contractor must flag the system
Scale: �" � �C�
PCHD, rev. 10/12/99
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�1EL� PER11�II7C�
1'�LEASE SEE �l.TTAC�'iEI) PLAN FOR WELL SITE LAYOU'I'
Tax Map #: ,,��. Pazce1 #�.�._ Township �/�'v�,�.'��
Applicant ���r �� r�i�s -
Subdivision: l/��„1/� � i�� 'r C Ge� Section: Lot !�
Ty�e of Water Suvvlv: ,�Individual Communitp Public
Rec�uirements:
Site Approved by �t.�.� ��-�D�of
Grouting A proved by �f� �O-D/
Well Log - 1- /5'-d
Well Ta.�df� l� !.S-r�/
Air Vent ���' /� / 5 =o/ -
Hose Bib ,���/ � ! � 0/
Concrete Slab /2� � /5 -e/
Well Driller. ..L�rrt�7T�
Well Approved �y: �� . l�ate:�-,/.�d/
'Q°i°5ee Attached Site Sketch�
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from anp building founda.tion.
013�er conditions• Sc� .��7'-P �'�7�1� —
PC�ID, rev. 09/07/01
Barnette Well Drilling Inc 336 598 92:5 �1/�8/02 �9:12A P.001
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' . PERSON COUNTY ENVIRQNMEHTA7 HEALTFI �
41L• LL LOC
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Date: 1�.-�1-c�r '
Owner: /1'1 � ��-`l� r S�# '
Locationlz7ixections: r��:�.� %:�Q �-� _ - '
Subdivision �Name: vS�l V � -2 I.ot ��
Drilling Contractor:^ ���.�i r ..� �c „_`
WELL CONSTRUC'I'�ON
Distance hom Nearest �roperry Line 1 U Distance from Source of
Poilution l G a � (� !�G �
Total.Depth:_ �� Ft� Xield: ! GPM Static Waccr �,evel�Ft.
Water Bearing Zones: Depth Ft. Fc. �� Fc. Fc.
Casing: Depth: From_�„_,to�..(�..-�Ft. Di�metc�f,�_�nches
TX,P�: Steel ' Galvani2ed Steel
T,f Stcel, does owner approve: � Yes No
� Weigh�: � ___ Thickn�,ss:��,_ Height�Abov� Ground: I`�1 Inches
Drive Shoe: Yes ./ No .
Were Problems �ncountered in Setting the Casing? 'Yes No �
. If "yes" giy c r�:ason:
Grouc: Type: N�at SandlCement % Conerctc
Annular Spacc Width � Inches
Wacer in A�mular Space: Yes__ __ __ Na
_ . Method: Pumpcd Pr�.sSure � Pourzti �' -
�7epth: Fr�m �1 to � C� Ft.
Materials Used: No. �ags Ponland Cemer�t Weighc of .1 bag�, lbs.
�f' mixtwce (sand, gravel, cuctinas} - Ratio: to
�TD P�ates: ies � No � �
� 4 x 4 slab Yes i No
X HERLBY CER'��FY THAT T.f-T� ABOV� INFORM�'I�ON IS CORRECT AND THAT
T�s WELL WAS CONSTRUCTED IN ACCORDANCE WrI'H IZEGULATIUN5 St::T
FORTH $y�THE P�RSO�t Cvui�l'TY HEALTH D�I'ARTMF
�✓� � w_ _./.2 �2./ -_o�
Sign turc af Co actor I�at�
. . Pee�on C�iu� Haaitlt �Q�'�t � .
E.�vircraa�entai �6�i4�t Saction. • . / �.?3
. 'tax ii� � � �
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; APP� � �
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� Qpe�ation-...Permi�t �
� . � SYat�t Type (in A�u�ce Vl�h Tab� Ve):
Tt�S 81l'S7'E�1 �ULS BEH�1 INSTALLE'� IN CONPLJANC� iN11'ti APPLtC�1BL.E MORiH
CAROLJNA t�ENE�RAL STATt3iES. RULES FOR SEINAOE TREA'i!�ldT AND DISP08AL-:
� .AND ALL CONDRlON9 OF THE IYPROV01B�f P6i111'f � AND CONSTRUCTION
AUTHORIZ TION� _ .
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