A29 195Applicatian Date: 3 '1�-do
Amount Paid: r.3'[3�-
Receipt #: .� i � ��f �# 3,�` p
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Person Countv Heaith Department
Environmental Health Section
APPLICATION FOR SERVICES
Tax Man #: �' ��
Parcel #: I 9 S�
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 INVALID.
1) Permi: requested by: (Ownerlagent/prospective owner): f%�►'++ �w ��� ��- ��
Home Phone: �/9-5G �- �f/7� Address: v 1,�1. r • .. �
Business Phone: 9/9• 3cut-Zz�f�/ t�n e a,,, Q, � �� c� 7�cZ
2) Name and address of cuRent owner: �i/+n-eti-' U�+/���-
- -3p� Lv. C'�•�1�'i%C3-3+.s �y, .
w, � d a.Y..e �..�4 ,c �:27 � o�
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3) Property Description: �ot size: 1 r 3' Township: ��e • d% 11
Oirections to the prope�(in�cicuding road names and numbers);
P� 1�W �J`l�h e i�if. %b f
�f
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G'Cja �
4) � Proposed Use and Structure Description: answer each of the following questions:
a) Proposed NYExisting ❑ � o
b) Stick Built 0, Modular �in le Wi D uble Wide [T�
c) Number of Bedrooms:�.� ,��g�j�d) Number of occupants or people to be served: ,�
e) Basement: Yes �, No yes, # of ase ent fixtures:
� Garbage Disposal: Yes 0, No L�
g) Dimensions of Proposed Structure: Width: �, Depth: 2D
5) Water Supply Type: Private 9'(new � or existing 0), Public �. Commun'ity 0, Spring �
Are any wells on adjoining property? Yes � No �-lfyes, location
6) Please Indicate Desired System Type: (systems can be ranked in order of your prefe�ence)
�Conventional 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 SITE PLAN TO THIS APPLICATION
I hereby make application to the Person County Health Depa�tment for a site evaluation for the on-site sewage disposal system for
the above-described property. I agree that the conte�ts of this application are true and represent the maximum facilities to be
placed on the property. I understand if the site is altered or the irttended use changes, the peRnit shall become invalid. i understand
that as applicant, i am responsible fo� identifying and martcing property lines, comers and making the site accessibte for the
personnel of the Person County Heatth Oepartment to conduct their evaluations. l understand that I am responsible for no6fying the
Health Department if my property contains any wetlands as designated by the Army Corps of Engineers.
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Owner or Legal Represe�tative Date
PCHD, rev. 10/12/99
�
PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND S
Tax Map #:
Zoning _
Parcel # C ��
Township �L � �� ` t ' L(
. �ii ��r�,�w���a�����.�•�.�—..r.�.:.�. _ ,_. _�
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, . • - � Ir�J/I/[��I�L�![� -- � � - —
Improverr�ent Permit
�nt 6e issued with onlv a
/ r��� i �-
New ✓ Repair _ Addition _ Type of Structure-�. Water Suppl _
('�T S-�o -a d
# of Occupants � # of Bedrooms _��rl Other •
Basement? ,�(Z Basement Fixtures?
Projected Daily Flow: � g.p.d. Permit Valid For: �ive Years ❑ No Expiration
Proposed Wastewater System T pe:��� W UI. a���>� t`�f
Pump Required? Yes �No ^
Permit Conditions:
- —� �' � J `/ l � � � 6ZJ�
Owner or Legal Representative Signature: �� '�,..� �� Date: S-� Z�
Authorized State Agent: {� � Date: ' � -
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 meeting 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 pertnit is subject to compliance with the provisfons of the
Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code.
Authorization To Construct Wastewater Svstem (Required for Buildinq Permit)
Type of Wast water System '. 1/�� '�l Wastewater Flow: �g.p.d.
Facility Type: GJ 1� t I�ew �Repair OE�xpaYeis n❑/
Basement? O Yes o Basement Fixtures. ❑ �'N
Wastewater Svstem Requirements
Septic Tank Size: � gallons Pump Tank Size: N I� gallons
�33
Total Trench Length: ,�_ feet Maximum Trench Depth: � inches Aggregate Depth:�in.
���� oil Cover: � inches Trench Separation: �, Feet on Center
othe�:s�-f �l G-� V l�I`J�1 G�P,f�V'-�t/1/I ,� ��.5/TG �1��% �(���•
Permit Expiration Date: ��-� � ^ �S
Authorized State Agent: . ��/(�l..C�(/�tnate:���.�CD
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The type of system permitted ❑ does Q does no differ from the type specified on the application. I accept
the specifications of this permit.
Owner/Legal Representative Signatur • -- ^a�:
PCHD, rev/ 10/12/99
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PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: � �
Parce� � `� "
Zoning
Township � � � �/� � � � �
Applicant ���nn� � ' ^� `� -
�r �PLocaUon: � k
Subdivlsion:
TYpe of Water SupplY:
Requirements•
LoL �_
Weil Permit
✓Individual Community Public
Site Approved by _✓_.���
Grouting A',Proved by ✓ ' `��
Weli Log ✓ ,/�f� �' 21 ' ��0
Well Tag;/ �� �_
Air Vent ✓ � � � ��
Hose Bib �
Concrete Slab
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**See 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 any building foundation.
Other conditions:
PCHD, rev. 11/29l99
0
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date: ���9-od '
4wner. 7"� 1;�, �� - � SR# ' . . �
Location/Directions: ��a ��P� �o�� r��'-� � � �
Subdivision �Name: Lot #
Drilling Contractor:^ c��t( � 2,�;F�► � nc
� WELI. CONSTRUCTION
Distance from Nearest Properry Line I v Distance from Source of
Pollution ( G a
Total.Dep.th: � D Ft. Yield: �f G M Static Water Level a?..r' Ft.
Water Bearing Zones: Depth % t. 7�[. Ft� F�.
Casing: Depth: From 6 to 3_ t. Diameter: Inches
TYPE: Steel � Galvanized Steel
If Steel, does owner approve: Y�s No
� Weight: � Thickness:� '� Height�Above Ground: /�/ Inches
Drive Shoe: Yes ✓ No . � i
Were Problems Encountered in Setting the Casing? Yes No � '
If "yes" give reason: �
Grout: Type: Neat Sand/Cement / Concrete '
Annular. Space Width � Inches .
Water in Aimular Space: Yes No
_ .. Method: Pumped - Pressure � - Poured � � - � - - -
Depth: Fr�m O to � O FG �
Materials Used: No. Bags Portland Cement Weight of .1 bag__lbs. �
If mixture (sand, gravel; cuttings) - Ratio: to
ID Piates: Yes � No � � �
� 4 x 4 slab Yes i No
I HEREBY CERTIFY THAT THE ABOVE INFORM�TION IS CO�RECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSO�t C�'viJTY HEALTH DEPARTMENT.
� Signaturc of Contractor Date
Person County Health Department
�, Environmental Health Section
Tax Map #: r' Z� Parcel #: ��
Zoning: Township: �LG , GIIiL�
Subdivision: ,�f��%� � � C��%C� Section: Lot: �
Applicant: �f���� �� f�������1d�,
Location• 5 tC � .� l{� l�-�� ��P '"'` "
�iQG1 � �Lf ���d`�i` � � � .
Operation erm 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 ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZATION.
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Tax Map #: �" 2� Parcel #: i� 5
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t 20'
131'
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PCHD, rev. 10/12/99