A29 192r
AQalication Date: 3-1�`6 �
AmountPaid: 0.00
F�eceipt #: �
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Person CountY Health Department
Environmentai Health Section
Tax Map #• �� �
Parcel #: � � 'Z-
. APPLlCAT10N FOR SERVICES �
IF THE INFORMATION IN THE APPUCATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED. CHANGED, OR THE_SITE IS
ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORiZATION TO CONSTRUCT SHALL BECOME INVALID.
1) Permit requested by: (Ownerlagent/prospective owner): f%��'►+'� ��� i�
Home Pho�e: ��j9-5� �'- �/7'�' Address: d I.�. �^ :� 1�.
Business Phone: �i/9.3�-az�{y Vr� e a�.., �f v� e.� zy�c�
2)
3)
Name and address of current owner. �/w►•e.v�' pa'�'. ��-
30�. l.t:• t���%c�s... �.
v►.,.P6�.r.x � .c_ > �7 �s� �
d2 �4 C
Property Description: �ot size: r�� Township: ,t ��% 11
Directions to the property (including road names and numbers): �f s�
•�
ocp �
4) P�oposed Use and Structure Description: answer each of the following questions:
a) Proposed 6!Existing � ,
b) Stick Built �, Modular �ingle Wde �, Double Wde �'
c) Number of Bedrooms: � d) Number of occupants or peopte to be served:
e) Basement: Yes �, No A�I'f yes, # of basement fixtures:
� Garbage Disposal: Yes 0, No �}--"
g) Dimensions of Proposed Structure: Width: � Depth: �
� Water Supply Type: Private�'(new Q o� existing 0), Public q Commun'�ty �, Spring Q
Are any welis on adjoining property? Yes Q No �-if'yes, location
6) Please Indicate Desired System Type: (systems can be ranked 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 ATTACH SURVEY PLAT OR SRE PLAN TO THIS APPUCATION
I he�eby make applicatio� to the Person County Heaith 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 fadGties to be
placed on the property. 1 understand if the site is altered or the intended use changes, the permit shall become invalid. i understand
that as applicant, 1 am responsible for identifying and marking property. lines� comers and making the site accessibte for the
personnel of the Person Caunty Health Depa�tment to conduct therc evaluations. l understand that I am responsible for notifying the
Health Department if my property contains any wedands as designated by the Army Corps of Engineers.
��.� %.���.� 3 � �f O�
Owner or Legal Representative Date
.
PCHD, rev. 10/12/99
s
PLEASE SEE ATT
Tax Map #: � 1
Zoning
Applicant
Locatlon:
Subdivisii
AN
Parcel # ��
Townshtp �Vi V �- I —
�� �� t � � -� f �O��u C(�cl�
� -�' � ��' t � �.
� e � l � l� SecUon: Lot:� (�'LY ��t,U l�l /V l� Iu�l
Im rovement Permit �� wl C( ������
p ; �rr�� �F cr�c��
A buildinq permit cannot be issued with onlv an improvement Perm t
New+/ Repair_ Addition _ Type of Structure��. Water Supply�r�v�-e �� �' ��91' �-
# of Occupant �# of Bedrooms Other •
Basement? � Basement Fixtures�
Projected Daily Flow: � g.p.d. Permit Valid For: C�YFive Years ❑ No Expiration
Proposed Wastewater System Ty e:�(,��1 �l`� %L �(�`�� �i���%i` H'���/ ' wl��/�'L I.U�V �-f
Pump Required? Yes �No �Y�,V � �Q)
� � r,. , . �i � � �
Pennit Conditions:.
— 0 -F(D Vl� I S� '��1 �l/�i0('�.�1� C�,l�-
Owner or Legal Representative Signatu : Date: /"���
Authorized State Agent: ` Date:
The issuance of this permit by the Health Depa�tment 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 plan, plat, or the intended use changes. The Improvement Permlt 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 Disposal Sysbems of the North Carolina Administrative Code.
Authorization To Construct Wastewater Svstem (Required for Buildina Permit)
Type of Wast,gwa � S ste l astewater Flow: �g.p.d.
5
FacilityType: CL� t��� Ne epairOExpansion0
Basement? O Yes Gl.Pd' Basernent Fixtures? 0 Yes tCl�o
Wastewater Svstem Reauirements
Septic Tank Size: ,�,QQ.� ga�lons Pump Tank Size: N!� gallons
Total Trench Length: �_ feet Maximum Trench Depth: � inches Aggregate Depth:�Zin.
Mi►� �
Maximar�n Soil Cover: � inches Trench Separation: �^ Feet on Center
• - 1�Irl�.Rl�rL•J[/��1r1��i�r.��,•�
. . ._ - �
��o
Authorized State
��(r�c�l5 wtC�-�°�
The type of system permitted ❑ does Q does not differ from the type specified on the application. I accept
the specifications of this permit.
�wner/Legal ReNresentative Signatu . , a�= ���
?CHD, rev/ 10/12/99
0
Application #:
Tax Map #: �
Parcel #:
Person County Health Department
Environmental Health Section
SITE SKETCH
� ,U (� _ .�r��U� (I � C�v�Gle l�t �
�� Applicant's Name � Subdivision/Section/Lot#
r I .�� 7-�I-oD
thorized State Age t Date
System components represent approzimate contours only. The contractor must flag the system
to beginnin� the installation to insure that proper gra�te is maintaine�
Scale: 1�1,�"� SC���
PCHD, rev. 90/12/99
PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
/� G� PB��� f �' 2
Tax �AsP �k: � I � I
Zoning
Townthip n / � f ( %� / ► �i (
Applicant
�ocation:
����, � I �� I �Gl �iSection: �O� �
Subdivislon: ..., -
Well Permit
�ae of Water Suaaiv: ✓Individual Community Public
Requirements:
Site Approved
Grouting Ap r�
Weil Log
Well Tag
Air Vent �
Hose Bib—%
Concrete Slab
Well Driller
Well Appro
�� �� .
• • ri �j
S
Date• �U Jl ✓ � �
'""kSee Attached Site Sketch**
'�Wells must be 10 feet from property fines.
�Wells must be 100 feet from septic systems. .
.�Wells must be at least 25 feet from any building foundation. �� ��
Other conditions: �PGU,I GI.(� �,�l�l DI I�L�� ��� � �G
� ���P�-5.
PCHD, rev. 11/29l99
Date:�2S
Owner.
Location/Di
ions:
Subdivision—Name: _
Drilling Contractor: �
WELL CONSTRUCTION �
Distance from Nearest Properry Line I v Distance from Source of
PERSON COUNTY ENVIRONMENTAL HEALTH
T
WELL LOG
_SR# '�� �
� �, c� c -r r�____�'P�, c `. � �1�
Lot #
Pollution t G �
Total.Dep.th: Ft. Yield: Z GPM Static Water Level a.S—' Ft.
Water Bearing Zones: Depth �i �_Ft. � Ft� Ft� Ft.
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 r�ason:
Grout: Type: Neat Sand/Cement / Concrete
Annular Space Width � Inches
Water in Annular Space: Yes No
_ .. Method: Pumped - Pr:ssure � Poured i - � � .
� Depth: Fr�m 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 i No
I HEREBY CERTIFY THAT THE ABOVE 1NFORMr�TION IS CORRECT AND THAT
T�S WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON COui�TY HEALTH DEPARTMENT.
f
• ` � /. .._-_
gnature of Contractor a«-
Person County Health Department
. � Q, q Environmental Health Section ��a
Tax Map #: 1-1 a I Parcel #:
�oning: Township: V �� C- i�i � 1 �
Subdivision: ��5� � � ���- C}rL�G Section: Lot: �
Applicant: �1 rnc� ,Da�vr.s .
Location• ����v�rLc�Do %�-
Operation Perm it
System Type (In Accordance With Table Va): �
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND�� �L CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTFtORIZATION. /1
State Agent
�� /�g a 1
Date
Tax Map #: Parcel #:
PCHD, rev. 10/12/99