A29 200—��o,s�.s��� �t-a
�+ 1 Tax Map #: �O2 �
A lication Date• 3'�-�d ,L� �
Amount Paid: : � :!'��C' � . `�'( �
Receipt #: �� 0 2 � �p�► � � Parcel #: `� � O
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• "- 7`� P rson Coun Heaith De artment �
� �-- ��a 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 SHALL BECOME INVALID.
1) Pertnit requested by: (Owner/agenUprospective owner): E%�►'f+ ���� ` 5-
Home Phone: �I`I-5��'—lf/7'�? Address: '? o I,J. r' 1�.
Business Phone: 9/9� 3o4-zz�{y i�a e �� e. � p y��
2) Name and address of cuRent owner. �/wt,ev�' A�►`�- _
��P�. Lt;• c.y7�ti,Cts... �,
�►�,�abl.t.�.e . an ac ° 27 � L
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3) Property Description: �ot size: � Township: ,r �t d> 11
Direcfions to the propertv (including road names and numbers);
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4) Proposed Use and Structure Description: answe� each of the following questions:
a) Proposed L9!Existing � ,
b) Stick Built �, Modular �ingie Wide �, Double Wde �
c) Number of Bedrooms: �, d) Number of occupants or people to be served:
e) Basement: Yes 0. No B'tf yes, # of basement fuctu�es:
� Garbage Disposal: Yes �, No 6�--'
g) Dimensions of Proposed Structure: Width: �, Depth: ��
5� Water Supply Type: Private°9'(new � or existing �), Public Q Commun'�ty �. Spring ❑
Are any welis on adjoining property? Yes 0 No �-iPyes, lacation
6) Ptease lndicate 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 LlNES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SRE PLAN TO THIS APPI.ICA710N
L�- I �
I hereby make application to the Person County Health Department for a site evatuation far the on-site sewage disposai system for
the above-described property. 1 agres that the contents of this application are true and represent the maximum faciGties to be
placed on the property. I understand if the site is altered or the i�ended use changes, the pertnit shall become invalid. I understand
that as applicant, 1 am responsible fer identifying and marking property. lines� comers and making the site accessible for the
person�ei of the Person County Health Department to condud thei� evaluations. I understand that I am responsible for notifying the
Health Department if my property contains any wetlands as designated by the Army Corps af Engineers.
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, Owner or Legal Representative Oate
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Applicam
Location:
T��x �v1�a�� ! ' P�rc�el µ _� .
S�����h�l!ivis�i�on .'„ , - �
Fh��s�e Sect�ion Lot �
�/ Improvement�Permit
Permit Valid for � Fiv Years _ No Expirallon �.
Type of Facility: i USG New �Addition _ Water Supply 1�✓�
# of Occupants # of Bedrooms ,� Projected Daily Flow 3 o g.p.d.
Proposed Wastewater System: � Type: ��
Proposed Repair: �/ �,cJ •,u Type:
Permit Conditions: �//a�,, � � �i.,{y,��
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Owner or Legal Representative Si ature: " Date: o �
Authorized State Agent: Date: � zs �o Z
The issuarice of this permit by the Health Departmen�-1'n does not guarantee the issuance of other pemiits. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This
�Improvement Permit ie aubJect to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rules for Sewage Treatment and Disposal Svstems' (15A NCAC iSA .1900).
� Authorization to Construct Wastewater System (Required for Building Permit)
* See site plan and additional attachments (_J.
` Pro osed Wastewater S stem:_ __ �/ y�� � T e.� Wastewater Flow D. d.
P Y �✓� YP �_ s�� P•
New ✓ Repair Expansion _ Soil LTAR: �� g.p.d./ ft 2
Type of Facility: _ ��r� Basement _ Yes �No
Wastewater System Requirements
Tank Size: Septic Tank: fb00 gal Pump Tank: -- gal Grease Trap: �' gal
Drainfield: Total Area: %Zo0 sq ft Total Length ��� ft Maximum Trench Depth �D in
Trench Width 3 ft Minimum Soil Cover: �o in Minimum Trench Separation: 9 ft
I Distribution:
�Specifications:
Distribution Box � Serial Distribution Pressure Manifold
Authorized State Agent: �"�/�
Permit Expiration Date:
Date• -z - _�
The type of system permitted is � Conve ' al Innovative Alternative. I accept the specifi� ions of
the permit. �1���%;� 9 -9 -�
Owner/Legal Representative: Date:���--
System Type (in accordance with Table Va)
The system has been installed in compliance with applic
Disposal, and all conditions of tha Improvement P�m�t
wastewater system will function properly for any�give�
Authorized State Agent:
Operation Permit
�_ �
able North Carolina General Statute, Laws and Rules for Sewage Treatment and
and Constntction Authorization. Issuance of this permit does not guarantee that the
periQd of time. n �
Date: � 11��
PCHD rev. O1/23/02
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Name �,��� � /.
S�bdivision O / ��'
Authorized Stat ent
SITE SKETCH
Tax Map # :�29 Parcel # Zao
Section/Lot# /Z
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Date
System components represent approximate contours only. 7'he contractor must flag the
system prior to be�innin� the installation to insure that �ro�er �;rade is maintained.
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WELL PERMIT
PLEASE SEE ATTACHED PI.AN FOR WELL SITE I:AYOUT
Tax Map #: ��. Parcel # ZD D Township �i rsf 4�r.L�
Applicant: P�,���,,.7�,�.�
Subdivision: D i��� ���C Section• LoL !Z
Location•
Ty�e of Water Sug�lv:
Rec�uirements•
�Individual
Site Approved bp V � � �"� �'�a
Grouting Approved by � � `�' "1 �'oa-
D�1Cll i.Og ✓�Ef �1'l?� �-
�(1e11'I� -� `l' � �2'
Air Vent ✓ � �t
Hose Bib ✓ � �
Concrete Slab ✓�N 1-�4 •a�'
Communitp Public
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Well Driller.
Well Approved By: ` Date: %`��� � �
-'�°5ee Attached Site Sketch'�°k
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet kom anp building foundation.
Other conditions:
PCFID, rev. 09/07/01
Barnette Well Drilling Inc 336 598 9275
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iE��s�,r„ „�„ .�.�,���..Il JHC� �JI,�Ih.. � � " a �-/� -02
VVcll Log
Owner. � a ��._._�_ Tax lt��p�� Parccl #%�
LoCation: �/i✓c! �ac�v ��!
subdivision: �oS�,://� C ;«l� �t� /�
WeII CoAstruction
Distar�ce From ncarest Property Line (Min�iAaum ZO feet)
Distancc from Sepric Systerxa (M�inimum 60 feet)
Y'ot�1 Depth: � ft Yield: %� GPM Static Water Level: �?S ft
Water Bearing, Zones: D�-pth Gl 7�tf� ft_�T ft ft
Casing:
Depth: From Q___. to �i(o ft. Diameter- (� � in
Type: Galvanized Steel �
Weight: Thickncss: . ids Height above Gmund: /5� in
Drivc Shoc: � No Any probiems encountered whiie setting casimg? Yes ,_�/l�to
If `�es" gitve re�Son_ --- -.--__ --_
Grout;
Neat: Sand/C:ement ✓ Concrete . GravcVCemcnt _
Aanular Space Width ,� __ inchcs Watec in Annular Space _
Mcthod o£Grout: Pumped � Pressure Poured ✓ �epth
Matcrinls YTscd:
No. Bags �ortland cement y� Wei�t of 1 Ba� �5D Pourtds
If raixturc {sand, �nvel, cuttiugs} — Ratio t�
ID p�ates: ✓Yes _ No 4 x 4 slab ,_✓Ycs _ No .
�'rom
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Urillin�; Y.og
Formation
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Yes � No
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Location Dc�win�
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� hereby ee�tiEy that tbe above in�ormatioa is comet aud that this weil was eonsnvececl in aeeordance with regulations
set forth by thc Person Caunty Health I)epar�ne t.
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Si�naturc of Contractor , ^
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Applicant:
Location:
r D�,v iS
T��x M�p ' - " P�rc�el » -
Subcl�ivi�sion ��
Ph�s�e Sec�t�io���� �Lo�t #
Operation Permit
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,
A ALL CONDITIONS OF TkIE IMPROVEMENT PERMIT . AND CONSTRUCTION
T ORIZATIO .
.. ��i�`� _
Authorized State Agent Date �
Installed By: cat-E �c��c�, Date: / -/7—O� .
�-�� aS" T�-�►�.d �p�
PCHD, �ev. 07/29/02
S�3��IC TANK INSPECTION CtiE��Cl.1Si' (Type II - M
TaY MaQ # oi`� Parcei # 0 0� System Type (Table Va) �
OwnerlAppiicant �Imc� Qa.v is . Subdivision 2o5cc� i lt L Ci rc, (z
Address/Location p) + v c+- Loo� �,..d� Sec/Phase Lot # la
Septic Tank n� a ate �tn cat�on ines n�t�a ate
State ID/date �T�f3 I`� Sae o� SH- R-t�-a Trench Width ft. 3}� q-� �-oa
Capaciiy. � f�c'� . gal. Trench. Depth � fn. ✓ ��
Tee and Flter Trench Length � ft.
Baffle Trench Grade �/
� Sealant Trench S acing
Riser if applicable Rock Depth and Quality
Tank Outlet.Seal Dams/Stepdowns etc.
Permanent Marker Pressure Laterals i•1 ��
Pump Yank ti1 Hole Spacing
tate ate o e ize
Capacity gai. Pipe Sleeve
Waterproof /Sealant Tum-ups/Protectors '
Riser Required Setbacks
Water Tight From Wells �.
Pump From Property lines
Check Valve/Gate Valve __ � Structures/Basements :
nti-siphon o e Ditc es ramage ays
Fioats/Swiiches � . __ . .. : . .. . Surface Waters � � �
_ �
Alarm visable and audible Public Water Supplies
Electrical Components Vertical Cuts (>2 ft.
Rate (gpm Water �Lines ' �
Approved Pump Model Vehicle Traffic �
Block Under Pump Adjacent Systems ' �/
Pump Removaf Rope/Chain Easements/Right of Ways ti/
Distribution System Other �
Serial Distribution ' � Easements Recorded .
ressure an o d �� p . ert ie perator ntract
Low Pressure Pipe • � Tri-Partate Agreement
Appr. Pipe Material and Grade
Valves �
Comments� �
pchd rev. 3/13/01