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A29 191, � Application Date: 3' ��'� � Amount Paid: t.�6.0U Receiqt #: � r z�� . ��:$ 3700 d °° � � ��' A 3,6 Perso� Countv Health Department Environmentai Health Section Tax MaQ #• /"�' °2 � Parcel #: 1 � � . APPLICATION FOR SERVICES . IF THE INFORMATiON IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFiED CHANGED OR TNE SITE IS ALTERED, THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID 1) Pertnit requested by: (Owner/agenUprospective owner): ��t'f+ �w i��W� ` 5- Home Phone: ��19-.'r� ��- �f!`7'� Address: o I,J. �^ �� , Business Phone: 9/9• 3o+�-zzy�y � p ��, �, i,, e,. .� y��-� 2) Name and address of current owner. __ �%wi-e� p�'.'S- 3��. Lr;� cy��ici,�... �. � � iM �P � LimR �,,, j�( �C • �'7 �i '� - 3) Property Description: �otsize: 4�� qTownship: ,{ �� d%11 Directions to the property (Including road names and numbers): �f s• • �.. �'e`o +� 4) Proposed Use and Structure Description: answer each of the foilowing questions: a) Proposed l9!Existing Q b) Stick Built �, Modular �ingle Wde �, Double Wde [B�' � c) Number of Bedrooms: � d) Number of oa:upants or people to be served: e) Basement: Yes �. No B�Ifyes, # of basement fixtu�es: fl Garbage Disposal: Yes 0, No L� g) Dimensions of Proposed Struciure: Width: ,� Depth: � � Water Supply Type: Private+6�(new � or existing �), Public �. Commun'rty �, Spring � Are any wells on adjoining property? Yes 0 No 5a-tf'yes, loca6on 6) Please Indicate Desired System Type: (systems can be ranked in orde� of your preference) �/Conventional Modified Conventlonal _ Altemative Innovative Other (specify): CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY. STAKE THE CORNERS OF ALL PROPOSED STRUCTURES. PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPUCATION L�- 3 r--- t hereby make application to the Person County Heaith DepartmeM fo� a site evaluation for the on-site sewage disposal system for the above-described property. I agres that the conte�ts of this application are true and represent the maximum fadGties 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 as applicant, I am responsible fo� identifying and marlcing property. lines, camers and making the site accessible for the personnel of the Person County Health Department to condud therc evaluations. I understand that I am responsible for notifying the Heatth Department if my property contains any wetlands as designated by the Army Corps of Engineers. /l�.-�/ �.00-,-=—�.-� ,3 � �f ^ �� Owner or Legal RepresentaGve Date PCHD, rev/10ft9'99 � . , r PLEASE SEE ATTACHED PLA� Tax Map #: / 1 �" I Zoning Appllcant: ` V �'� � �jGj (� / Location:" l � � � Subdivision: l i Section: Parcel # � I Townshlp � LAYOUT Lot: �_. Improvement Permit A buiidinq permit cannot be issued with oniv an Imarovement Permit New� Repair _, Addition _ Type of StructureY�• 1Nater Supply�YC��y�/' _ �'��w( # of Occup�ants # of Bedrooms � Other • Basement. Basement Fixtures? Projected Daily Flow: � g.p.d. Permit Valid For: �ve Years ❑ No Expiration Proposed Wastewater System Ty�p :(',��i ��{1 f'� �[ �(�Q,� a%'�1�CL � Q� � r P Pump Required? Yes ✓ No —% � � � . Permit Owner or Legal Representative S Authorized State Agent: ,� C�r��r o✓�( 9raU�ty �� S / / s 'i . .ii� � � . ��.��.�: •. t � v The issuance of this permit by the Health 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 with the provisions of the Laws and Rules for Sewage Treatment and Dispasal Systems of the North Carolina Administrative Code. Authorization To Construct Wastewater Svstem (Required for Buildina Permit) Type of Wastewater S stem Wastewater Flow: �g.p.d. 31.�G� Dpw��,�r`- rau � Facility Type: G�1 e��Repair OExpansion ❑ Basement? 0 Yes o Basement Fixtures? 0 Yes �o Wastewater Svstem Requirements Septic Tank Size: �_ gallons Pump Tank Size: � 9allons Total Trench Length: � feet Maximum Trench Depth: �� inches Aggregate Depth: % in. Idfs�a�-6oil Cover. � inches Trench Separation: � Feet on Center Other: i�dl�� /�� ` `"' Permit pira ion Dat�s � ` �� —d� Authorized State Agent /".yi/1/��l �l -��2��Date: 7-?�l DD The type of system permitted ❑ does Q does not differ from the type specified on the application. I accept the specifications of this permit. Owner/Legal Representative Signature: (�1��''� Da� � �� PCHD, rev/ 10/12/99 � � s� I��I�� :� �, ,/� y�y \.i• .,v� /.1 J �^ � V �� Y. � I��.�a-�,,,,,.,.,, �ffi��.11 IE-��.Il�l�. SITE SKETCH. Name ��/�1�(r �U� S SU �1V1SlOn � � C �'� . 1 - .S utho�ized State Agent Tag Map # �?� Parcel # �� Section/Lot#��t I [� <lF'C�� Idf 3 4- 2lQ -02 Date System components represent apprvxin�ate�contours only. The contractor must flag the systemprior to beginning the installation to insure thu:t�iropergrade is maintained � Scale• � � � - %� � '' i 6��"d,�,� Vl L�lT (CC�,f � 6� �! G'l �S Dd� �� e�� sf�,c ��- L�s-� co � c��, -��oc� ��Q�� lUl�� G�� 1/��1 V loWl� e,�.6�d'.c�--�C D�I � T��ec� r��► �(�� 5�� c-t,�d �� ; �. exc�� c � << - ��. . ,� ��_� � �, �J P . � (�.� � �. � :�. ��` ` ' . ��'f x� �.>; °� , � � �~ �' � ` � �`y G � �- ti! � � �� r / , \\ .�1� 1 �` �> Y f� � . � �� ,/ � � �/ �,�`' � . ' O��/,�O �� ` � �O r ,,� � /.� PERSON COUNTY ENVIRONMENTAL HEALTH PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax IiAaP �: �"� Parcel # I 1 I Zonfng Township (J� � �/� V' V�� /►PPlicanG U� V V t V I J✓ N/v �/ •. LocaUon: � 1` f � Subdivlslon• �l%Ci�� l `P: �([�/� � Seetion• Lot �. Welt Permit �pe of Water�Suaalv: ✓ Individual Community Public Reauirements• Site Approved by Grouting Approved by � � � "� �� Weil Log lo � t -c� Well Ta - Air Vent -- --� Hose Bib� ' � � �� Concrete STab 9 �-�Z Weli Driller: Weli Approved •�--- _ .._..__.� � y�� 7�8 ' � —� Z.�' Date: � � **See Attached Site Sketch** elis must be 10 feet from property lines. Wells must be 100 feet from septic systems. ells must be at least 25 feet from any building foundation. Other conditions PCHO, rev. 11/29/99 . � ��,5� �� D � .34� � ` � � �� c,�n f��c lNC, � �h� . � IE��a-�� .�1 IL-33L��.11¢I� ��'0 �� (� - 7-D � Well Log Owner: �%�r� z l��a ►�� s _ Tax Map ,�� Parcel # 1 �i / Location: � Subdivision: Qo S �✓.//.e L�� lt Lot #�_ Well Construction Distance From nearest Property Line (Minimum 10 feet) Distance from Septic System (Minimum 60 feet) Total Depth: �/DD ft Yield: GPM Static Water Level: � ft Water Bearing Zones: Depth/ ft ft ft ft Casing: Depth: From _� to �_ ft. Diameter: � in Type: Galvanized Steel Weight: Tl 'ckness: , I g Height above Grounci: /y� in Drive Shoe: Yes No Any problems encountered while setting casing? Yes LiNo If `�es" give reason: Grout: Neat: Sand/Cement _� Concrete GraveUCement Annular Space Width inches Water in Annular Space Yes No Method of Grout: Pumped Pressure Poured �� Depth _� to �?Q Ft Materials Used: No. Bags Portland cement � s L� Weight of 1 Bag � D Pounds If mixture (sand, gravel, cuthngs) — Raho to ID plates: �Yes _ No 4 x 4 slab _ Yes _ No Drilling Log I.ocation Drawing From To Formation U�cr,��;- �ncJ%�"i y s�.lr� e �'.�j�.�ol � �� s�� D(�v� . ��'� �a s !o-F 7 � �x�Q� �3 I hereby certify that the above information is conect and that this well was constructed in accordance with regulations set forth by the Person County Health Departm Signature of Contractor � ID#��D2 y Date �'�7 -D� PCHD rev O1/16/02 , . � : �. . . :��,�. �� :,:I�I�II�:...�� - � � � � � � � �`_;.- •� : �:�,�-.�C�" � . : .::. .... . . . . . IE�� ffi��.IL ]E��.�:Il�. Tax Map #: �� ., . Parcei #• f � � Zoning: Townshlp: ��`�C �i << ' � 5� v i 1( C. C i`rC�:(,C;: ..•� � Subdtvislon: � . Sectlon: Lot: 3 Applicant: � I rn �� a v�`s Location• O� c u cr Lo� ' � a�ration Permit �. � :;:� System Type (In Accordance With Table Va): � THIS SYSTEM HAS BEEN IN'TALLED IN COMPLIANCE WITH APPLICABLE NORTH CAROLINA GENERAL STATUT�S, RULES FOR SEWAGE TREATMENT AND DISPOSAL, AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION Al!'ft�RiZATION. „ . . Authorized State Agent � 1 �� - r r �� ` � .'— c� M � U� . C�'G�O�' Date � � � � _ �,� ` �� T � T � � � �`�`�� `� ✓�<y - w�� .�� L �� wr�� lov� . �..� �� _ ,�.✓a�� d�/ 3�a,� - �/a i��S�,L . ��