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A29 204� ����� st,=�s-��5 ►a�s`� Person Countv Health Deaartment Environmental Health Section APPUCATION FOR SERVICES Tax Maa #• Parcel #: Laf� ( IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFlED CHANGED OR THE SITE IS ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID 1) Pertnit requested by: (Ownedagentlprospective owner): F�'aN k 1; .� �,� eN u y Home Phone: 5� 9 9— 23 � Address: 3 0 v� 1r u�Cq ���c� Business Phone: ax a ro,� San� e a`���-3 2) Name and address of current owner. �� . 3) Property Dascriptlon: Lot size: � Townshtp: ��S'4`y �G �� Directions to the propertv (Includinp road names and numbers): � 9 S G" 0 AS/�' -1e�� �S � 4) Proposed Use and Structure Description: answer each of the following questions: a) Proposed� Existing � b) Stick Built ❑, Modular ❑, Single Wide �, Double Wid� c) Number of Bedrooms: � � d) Number of occupants or people to be senred: e) Basemenr Yes ❑, No�f yes, # of basement fixtures: fl Garbage Disposal: Yes �, No 0 g) Dimensions of Proposed Structure: Width: � Depth: �� � Waber Supply Type: Private l�(new 0 or existlng 0), Public �, Community o, Spring ❑ Are any wells on adjoining property? Yes ❑ No 0 If yes, location 6) Please Indicate Desired System Type: (systems can be ranked in order of your preference) �Conventional lModified Conventlonal _ Altemative _Innovative Other (speclfy): CLEARLY STAKE ALL CORNERS AND UNES OF THE PROPERTY. STAKE THE CORNERS OF ALL PROPOSED STRUCTURES. PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO TH13 APPLlCATION I hereby make appiication to the Person County Health Department for a site evaluatlon for the on-site sewage disposal system for the above-described property. 1 agres that the contents 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 intended use changes, the permit shall become invalid. 1 understand that as applicant, i am responsible for identifying and marking property lines, comers and making the site accessible for the personnel of the Person County Health Department to condud their evaluations. I understand that I am responsible for notifying the Health Departrnent if my property contains any wetlands as designated by the Army Corps of Engineers. q - /�z-�a Owner Legal Representative . Date PCHD. rev. 10l12/99 . •�. . ,. PLEASE SEE ATT. Tax Nap � �P,� ,� K��� � �: ou �S C� Subdivision• Q h 1 � � ZoNng Township ��J� c�►u'i �u, � Gl Sectlon• � � improvement Permit A buiiding aermit cannot be issued with onlv an Imarovement Permit New�Repair _ Adcfition _ Type of Stnu�ure��S Water Suppiyj��' � I � # of Occupants �# of Bedrooms � Other ' Basement? asement Fbctures? Projected Daily Ftow:3 �v g.p.d. Pertnit Valid For. t'�Five Years ❑ No Expiration Proposed Wastewater Systerri�e:� dYtlre,�^�1��1a � Pump Required? Yes No . Permit Condfions:� �� Gl� 1 ��T� �'� ��+ Owner or Legal Represen 'v Signature: � Date: %l �� � `d 4 Autho�ized State Agen� r✓l Date: "� —� The issuance of this permit by the Health Departmerrt in no way guarantees the issuance of other pertnits- The peRnit hoider is responsible for checking with appropriale goveming bodies in meeting their requirements. This �iite is subJeat to revocatio� if the site plan, plat, or fhe intended use changes. The improvement Permit shall not be affected by a change in ownership of the aite. This permit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatment and Disposai Sysbems of the North Carolina Administrative Code. Type of Wastewater Facuity Type: B� �PS Basement? t] Yes o Wastewater Flow: 3�" �.p•d• New'�- Repair DExpanslon 0 Basement Fu�ures? 0 Yes �No Wastewater Svstem Reaulrements Septic Tank Size: �� 9al�ons Pump Tank Size: �� g���s � u Total Trench Length: �� feet AAaximum Trench Depth: �� inches Aggregate Depth: Z tn. r� m Soii Cover. � inches Trench Separation: ,� Feet on Cerrter . Other. �6 � V�VL�� W-� +r2,- (VIS��IQ��� . PeRnit Expiration Date: �—� ` Za� s Authorized State Agent: � �V'e� Date: L `� The type of system pertnitted ❑ does Q does not dlffer from the type specifled o� the applicatfon: I accept the specificatlons of this permit � Owner/Legai RePresentative Stgnature: Date: 1 I �� � o a PCHD, rev/ 10/12/99 - ..:; APPlication #: . " Tax Map #: Z _ : Parcel #: Zo�f � • Person County Health Department Environmental Health Section SiTE SKETCH ��� , /�✓� ih �'�n �� � � . Applicant's Name SubdivisioN ectioNLot# � . �� �� i�-� Authorized State Agent Date System components represent approximate contours only. The contractor murf�ag the system - , �rior to beginning the insiallc�ton to insure that proper grade is maintained _ s�-��-, o� : � q<< r� ,�� s��+�� ��-/ �a� S� . S}a<<��� �� � � K��' � � � l be.�°� 2. �`� � S��'nn ct�t- .�� S� "'" � S 7 ���-�,�r �`1`�° - n� �el�s i�` ��", � �, , , �Y ( , �,� a� 5, � J� . «; ,,� -�i.,� -t� ���5, (b'�'` (�� _� J � 31.5$ .� z.�s. �q, � .s��'� I U- Go' �.�r�,l �� � ����. � PCHD� cev. 9 Q/12199 r . ` PERSON COUNTY ENVIRONMENTAL HEALTH - PLEASE SEE ATTACHED PLAN FOR WEIL SITE LAYOUT Tax IIAap S: ��- � Parcai � �C/ � ZoMng Township � � ./ _ . .. ,� pppUcant: Locatlon: Subdivbion: Tvpe of Water Suaplv: Reauirements• Well Permit �dividuai Community Site Approved by ✓� �S � Z�i`V 1 Grouting Approved by/l�S -Z -c�j Well Log ✓(�S `� � Z`� � � Well Tag Air Vent Hose Bib Concrete Slab WeU Driller: �Y � - Well �Approved By: Date: '�'"`See Attached Site Sketch"'� Welis must be 10 feet from property lines. Welis must be 100 feet ftom septic systems. Wells must he at least 25 feet from any building foundation. Other conditions: Public PCHD, rev. 11/29/99 � PERSON COUNTY ENVIRONMENTAL HEALTH WELL LOG Date: �- ��-D/ Owner. %�'► � � SR# LocationjDirections: � Subdivision Name: __ fr���,� �% �-c Lot # 1 Drilling Contractor: � r .�c WELL CONSTRUCTION Distance from Nearest Properry Line I v Distance from Source of Pollution t G a Tota1.D"ep.th:� Ft. Yield: GPM Static Water Level QZ.Sr Ft. Water Bearing Zones: Depth ` Ft.,�F� F� Ft. Casin : De � th: From 6~�S Ft. Diameter: Inches g P ---�`� TYPE: Steel - Galvanized Steel If Steel, does owner approve: Yes No � � Weigh� � Thickness:� '� Height� Above Ground: /�/ Inches Drive Shoe: Yes ✓ No . Were Problems Encountered in Setting the Casing? Yes No � . If "yes" give reason: Grout: Type: Neat Sand/Cement / Coricrete Annular Space Width � Inches � . Water in Annular Space: Yes No _ .. Method: Pumped - Pressure � Poured � - � . . Depth: Fr�m O to �, C� Ft. Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs. If mixtuie (sand, gravel; cuttinas) - Ratio: to ID Plates: Yes � No � � � � 4 x 4 slab Yes � No I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTTH REGULATIONS SET FORTH BY�THE PERSON C�Li�TY HEALTH DEPARTME - _.��� ign ture of Contr ctor Datc � � : r � , � � Person Counfiy Health Departrnent �a � Environmentat �th�Section a a � Tax Map #: Znning: Townahip: (��ls�ti �t� Subdivisfon: �n k� i h��tn U S, b. Secttcn: _ L.oti 1- pppiic�trr� �i�ln � Lacatlon: � e . e�. �t' �LR i( C�e��y 1 �p��ration P�ermit System Type (In Accordance With Tabie Va): .�T b. %dn.v, THIS SYSTEM HAS BEEN INSTALLED IN COMPLlANCE WITH APPLICABLE NORTH CAROUNA GENEiZAL STATUTES, RULES FflR SEWAGE TREAT6AENT AND DISPOSAL, -AND ALL CONDITIONS OF THE lMPROVE�AEN'F PERMIT � AND CONSTRUCTION stat8 � I c ► � �� r�-jS=o� o� Ro�b l �s b�� t ' � �-��� �,, s �.� � ,, se� , ,�s� � - � . n�'h . . �S�•L�g f� ��S` � � i�S1E'prs �� J . n��5 � � ° �S � ,�b,fi �„S'���h�, �bi�i�s.�l b�. � �.� � __ b � � � � ►� 6� h �,�s��� �}, �; �►rb,h -�-� a i . y ��r� . �b � �� � „b`� 1I b'� � b , � ��,�h ��� �� �- r a �.�'r,.sa-�,�(,� �,.� . * . �IGk�nnQ.y IVu���� �..� ��Lar�r� � �4- g tl r-� il�`°1t u n ,�e,' K- , cr-� � i , PCHD, rev. 10l12/99 .