A29 194• ,' Application Date: �� ' %�`6 � � O � Tax Map #: � � {
Amount Paid: .S6.6U � "� � , �� � �
Receiat #: � D. . �� , ��� Parcel #: 1 � �
�37b .
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Person Countv Heafth Department
Environmental Heaith Section
. APPLICATION 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 SHA�L BECOME INVALID.
1) Permit requested by: (Owner/agenUprospective owne�): f!��'►� �e.w '��/� t�-
Home Phone: �Iq .SG+�- �/`7'�' Address: o i,J. �^ �.N ..
Business Phone: 9/9• 3c�-2z�fy in�, e a�. �,�,� e. �� y'3c�
2� Name and address of current owner. �/�n�e.Y-' 1��+/�'S-
3a� Lt.• t��1�c.f��.., �.
-tn,,•PBa...e,f,.y,r_ • �7 �e Z
3) Property Description: Lot size: �'� 6 Tow�ship: ,r � d% 11
Oirections to the aroaertv qnclud�nq road names and numbefs};
4) Proposed Use and Structure Description: answer esch of the foltowing questions:
a) Proposed L�. Existing 0 ,
b) Sticic Built �, Modular �ingle Wide �, Double Wide �'
c) Number of Bedrooms: � c� Number of oxupants or people to be served:
e) Basement Yes 0. No #�ifyes, # of basement fixtures:
fl Garbage Disposai: Yes �, No 0—
g) Dimensions of Proposed Structure: Width: ,� Depth: ,,,�
5� Water Suppiy Type: Private+B'(new � oc e�dsting �). Pubiic q Communrty O. Sprtng �
Are any wells on adjoining property? Yes Q No �Ifyes. location
6) Ptease indicate Desired System Type: (systems ca� be rat�ked in onie� of your preference)
. /Ccnventional Modified Conventional _ Altemative Innovative
Other (specify):
CLEARLY STAKE ALL CORNERS AND UNES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SCTE PLAN TO THlS APPUCA'f10N
I hereby make application to the Person County Health Department fo� a site evaluation for the on-site sewage disposal system for
the above-described property. I agree that the contents of this appGcation are true and represent the ma�dmum faaTties to be
ptaced on the property. I understand if the site is altered or the intended use changes, the permit shall become invatid. l understand
that as appGcant, I am �esponsible foc identifying and marking property. Gnes� comers and making the site accessibte for the
personnel of the Person CouMy Heatth Department to conduct their evaluatioc�s. l understand that I am responsible for notif�ring the
Health Departrnent if my property co�ains any we�ands as desigrtated by the Army Corps of Engineets.
��.�/ ,� �.� 3 � �'� oe�
Ovmer or Legal Representative Date
PCHD, rev. 10/12J99
May-15-00 07:56A
' `.
ERSON CQUNTY ENV1R0 ENTAL HEALTH
PLEASE SEE ATTACHED P FOR SQ1� AR A AND S'YSTEMI LAYpUT
Ta: �Ssp IF- I�i' � �
P�rc�l s
Zoninq Township _ OLl �/� /-�IL /
Appilca�t: •
Lo�ilOn: ���r�l G�r�' S
��,e s�-:�1-i� �- �
Subdirislon: e l% ► ( � � � ( ����;
Lo�; i�^
Imp�ovement Permit
New _�[ Repait Addition Type of fiuuctu�e � F-�
ii of Occupanis �# of Bedrooms �„ Olher
Basemerst? �/,�]_ Basement �ixhues?^/„�_
Water Supp�y �L � 1
projectec! Qaily Flow.��p �•p-d Permii Vatid For; �Ne Years ❑ No Expiration
Ptoposed Wastewatec System T � �
Pump Required? Yes�Nv
Proposed Repair ; r�,�����_
Perntit Conditioas:
n �� .
Owner or Lega{ Rap�esentative
O -�-0
oate� /
Authorized 5tate AgenL �
Oate:�
The issuance of tt�is permit by the Heafth Oepartment in no way gus�ant�es t1�e issuance of other pe�mits, The permit
holder is responsible tor thedcing yvith appropriato goveming hodies in mee6n9 theu requirements. 7hi3 slte is
subJect to revoca�lan tf the site ptan, p�at� or the inte�ded� use changes. The lmp�ovement Permit shall not be
aHected by a change in dv�mershfp a/ tt�e sitc, 7his permlt is subject to compliance yy�� ths provisions of the
Laws and Rules for Sewage Treatment and Oispvsal Systems of the No�th Ca�olina Adminiatrative Gode.
e,.a4..._...-•'-- � -
Type of Wastewa;er System Wastewater FIQrv:
��'G�9-P.d.
Facaliiy Typ�: �
easement? O Yes o
Waatewater g ytem Re uiren�enb
New O�tepair Q�xpan�ion O
Basement Fixtur�s7 Q Yes�ZQo
Septic TaNc Size: `�- s�� p�p T� Size•
Total Trench Length: t,�� �
Maximum Sal Cover, j� ���eS
• .,,_� gallons�
Maximum T e ch �D
P_02
�� t '��� �n
0
f0' $�p t� Q� ��d cl s,�i t,�
� N' �K�� �" , � a �
�' �� �°' a,\5�
� c,r ��r+
r n Oe th; ,�
P Inc es Aggregate Depth:,,� in. �.ows�
'irench Separatlon: � Feet qn Center
Other:
Pe�mit Expiration Date: T--
Authorized S�ate Ag�nt: �
Date`���/!�
�
1�-��0�"a
� �tl
�,w� r�c�
�
i h.�'f � � �� � d'�,
�� ��
The type of �yst�m partnitted q does O does not dift� Mom �� �� s�fted an tt►e appllcatl�n, 1 accept
tho SpeciBcat�ens of th1� pernti�
OwnerlLegal Repr�sehWtive Signature: � �i� oi � p/
oate: .
PCHD. rev. 11t18/99
. . . . �1��j /� ��.Lf. �1.�1.J �� . .
`�' � � � �T1��C�
�aa��r�TM++,� �aa�.m.�. ���.]��a
SITE SKE'I'CH
N e�1mtr' D�x.u;5 Tax Map #�a`1 Parcel #�`� ¢
S 's' n s�.� '(c C:j r'c 1� Section/Lot# �-P .
' !O - JI-OI
Authorized State Agent Date
Systesn components represent approximate contours only. The contractor mustflag the systemprior to
beginning the installation to insure that propergrade is maintained aA.,,�,,. �,..,r.�..rr�.A..m_.._,��__ -...-- .----•,.. ------
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WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: �°Z� Parcel # �� Township
Applicant:
Subdivision: ��� � �l� �° �'� Secrion: Lot: l..o
Location: �5� S � Nesfi�i s���.. rG'� � l�/• v� C..�� 2�
Twe of Water S���1�
Re�uirements:
" Individual Communi Public
— tY
Site Appro�ved by 1� �� ��"�' " d�
Grouting Approved by '��- i o` �'i-a�
Well Log / d -z�- �
Well Ta 7�� l�- �o ��%t
Air Vent 3 � I � " � -a �
Hose Bib 3 �+ � � -� � �
Concrete Slab � i-F � �" � -� �
Well Driller
We11 Appro�
��
���
�
Date: 1 ���0 "D �
- -J\.\. La�Ki\.ua,.1 Site Sketch'k*
Wells must be 10 feet from property lines.
Wells must be 100 feet from sepric systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
PCHD, rev. 09/07/01
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date: /0 1-�'�-O � .
Owner. . �_It �h���+P � SR#
Location/Directions: �
Subdivision Name: �o� � ; / � . � Lot #
Drilling Con�ractor: � � ��
WELL CONSTRUCTTON
Distance from Nearest Property Line I v Distance from Source of
�
Pollution ( G a
Total_Dep.th: r-/F� F� Yield: GPM Static Water Level a2.5—" Ft.
Water Bearing Zones: Dept}��°��.�"_"F[. F� � Ft� Ft.
Casing: Depth: From 6 to�_Ft. Diameter: Inches
TYPE: Steel - Galvanized Steel
If Steel, does owner approve: Yes No
� � Weighc: 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 Annular Space: Yes No
Method: Pumped - Pressure � Poureci
Depth: Fr�m O to � O F[.
Materials Used: No. Bags Portland Cement
If mixture (sand, gravel; cuttings) - Ratio:
ID Plates: Yes � No
4 x 4 slab Yes � No
i
Weight of .l bag lbs.
to
I HEREBY CERTIFY THAT THE ABOVE INFORM�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C^vLi�TY HEALTH DEPARTME .
��� 0 �-�I�-p i
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Sign ture of Contr c r Datc
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