A29 206� A Ilcation Date: ` ! ���
DD
Amount Paid: ' � � I � � 5 ( o �5�
Recei t #:
. � vy' ���
��12-� ��
� � � �f
S �����
� �l�-
Person Cauntv Health Deaartment
Environmentai Heaith Section
APPLICATION FOR SERVICES
Tax Mao #•
Parcei #:
IF THE INFORMATION IN THE APPLICATtON FOR AN IMPROVEMENT PERMIT IS FALSIFlED. CNANGED OR THE SITE IS
ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID
1) Fertnit requested by: (Ownedagarrtlprospective owner): F%UlU � j��J �, l7 e�: �%'
Home Phone: :5 `� q— �3 '%3 Address: 3 0 u ir � u r�Ctt;�
Business Phone: ok d r-0�
2) Name and address of currerrt owner: �a'�'� � ��`���
�� �
3) Property DeacripUon: Lot sfze: � T�; . g� S�y FG F�
Directions to the property (Induding road names and numt�e�s): � 9 S GO
4) Proposed Use and Structure Descripdon: answer each of the following questions:
a) Proposed�Existlng �
b) Stldc Buiit O, Modular �, Single Wide �, Double Wid�
c) Number of Bedrooms: � � � Number of occupaMs or people to be served:
e) Basemerrt Yes 0, No�f yes, # of basement fndures:
fl Garbage Disposal: Yes Q No ❑
9) Dimensions of Proposed Stnx�ure:lMdth: � Depth: ,��
� Watier Supply Type: Private�(new � ar e�ds�ng Oj, Public �, Community �, Spring ❑
�. Are any welis on adjoining property? Yes 0 No � If yes, locadon
6) Ptease indicate Desired System Type: (systems can be ranked in order of your preference)
�Comrerrtional _Modifled Conventional _ Altemative _Innovative
Other (apecify):
CI.FARLY STAKE ALL CORNERS AND L1NE5 OF THE PROPERTY.
$TAKE THE CORNEitS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PlAT OR SITE PLAN TO THIS APPLICATION
I hereby make appiic�tion to the Person County Health Department for a site evaluatlon for the on-site sewage disposal system for
the above-descxibed property. I agree that the conterits of this application are true and represerrt the maximum faalitles to be
placed on the property. I understand if the site is aftered or the intended use changes, the permit shall become invalid. I undarstand
that as applic�rrt, I am responsible for identifying and marking property tines, comers and making the site accessible for the
pessonnel of the Person Courriy Heatth Department to condud their evaluations. I understand that i am responsible for notifying the
Health Departrnent if my property contains any wetlands as designated by the Army Corps of Engineers.
� q-�a-�a � �
Owner Legal Representative . Date
PCHD. �►. �a�yss
.. � ' �
PLEA�
+ r.� n� �
• Zoning „_
�a s
Townsfilp f�`r� .
` Improvement Permit
A buiidina aennit cannot be issued with oniv an Imarovement Pennit
New Repalr _ Addih'on _ Type of SUudure �� Water Supply'�%i, l �
# of Occupants� # of Bedrooms � Other =
Basement? � Basement Fi�dures? —
Projeded Daily Flow: � g.p.d. Permit VaQd For. I'�Five Years O No Expiration
Proposed Wastewater'Systerri pe: lia►v� ��a
Pump Required? Yes No .
Permit Cond�ions:�� � � �`e�Cl-, -
Owner or Legal
Authorized StatE
Date• � /—� `� , ��
Date: �� �
The issuanca of thls permit by the Health Departmerrt in no way S�aranlees the issuance of othec permits: The pemnit
holder ts respons(ble for checking with approprtate goveming bodies in meeting thefr requirements. Thfs �►ite is
subJeat to revoaation If ths sita plan� plat, orlhe intended use changes. The Improvement Pertntt shail not be
affec�d by a change in ownership of the siie. This permtt ta subJect to compitance with the provisions of the
Laws and Rules for Sewage 7reatment and Disposa� 3l►stam$ Qf tfie North Carollna Administrative Code.
Type of Wastewater System
Facility Type: �
Basement? 0 Yes Nc
Wastewater Flow: �.p.d.
New � Repalr DExpanslon ❑
Basement Fixtures? 0 Yes RNo
Wa�+�ater 8vatem Reculrements
Saptic Tank Sfze: �.�1�. 9��ons Pwnp Tank Size: `� g���$
Total Trench Length:
`Z� fest Maximum Treru� Depth: �`inches Aggregate Depth: �Z In.
M�� . C{
�bFaxknum Soil Cover. � inches Trench Separation: l Feet on CeMer .
Date: �"��.�
� ��- c��-s,
The type of system pertnittsd O does C] doss not difFer from the type apecfffad on the application: I accept
the specificatfons of this pertnit �
Owner/Legal Representative Signature: /-� ��+ • ��� Date: � ' � -`�' v
PCHD, rev/ 10/12/99
�
Appiication #:
Tax Map #: �_
Parcei #: Za �
Person County Health Departrnent
Environmental Health Section
S1TE SKETCH
k19� � �� �� � � � 3
Applicant's Name . Subdivision/Sec ' n/Lot#
, ���
uthorized State Agent
i i —��—�
Date
Svstem components represent npprozunate contours oaly. The contractor must flag the systern
ta bepinning the insiallation to insure that proper grade is maintainec�
��`� G`'�����e���
�� ���,,,� b
'lv`Sk�<<� ++�.
1U_ "` � f
Scale: �
����.p7 �
PCHD, rev. 90/12199
' ' � ' ' PERSON COUNTY ENVIRONMENTAL HEALTH .
�. PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
� Tax Map 1R: / � � ` Parcei # � �
Zoning Township �/ ��;
AppUca� /�n (�� I' 1 �✓1 v�_ �
��o�: �� s. � f� r�e��
N i _ _ -�.� n �,.
Subdivkton• rT q �l (�I r
Ty_pe of Water Supplv:
Reauirements•
S
�
_i ��_Sectlo�• �
Weil Permit
c
�dividual Community � Public
Site Approved by ��� �` �� ° r
Grouting Approved by ✓ �� ' l �" ° /
Well Log
Well Tag �
Air Vent
Hose Bib
Concrete Slab
Well Drilier• ��`�rr`"e �
Well �Approved By: Date•
� **See Attached Site Sketch'"`�'
Weils must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Welis must he at least 25 feet from any building foundation.
Other conditions:
PCHD, rev. 11/29/99
PERSON COUNTY ENVZItONctENTAL HEALTFi
WELL LOG
Daie� /- �/-Ol '
Owner: �rk/:�
Lcxation/�i�ections:
SR# '
Subdivision �Name: _ �f r /; n i.oc #���
1?rilling Conaactor: � •�c
. W�LL. �ONS'CRUCTI�N
l�istance from Nearesc Properry Line__ I a Distance from Source of
Pollution ( G a
Total_Dep.ch:.__ !$0 Ft� Yield: `� GPM Static Water Level���
Water Bear�ng Zones: Depth ���� �'� � FL Ft.
Casing: Depth: �rom C� to�_F�. Diamcter: inches
TYPE: Steel • Galvanized Sccel
If Steel, does owner approve: Yes___,___No
'�Teight: � Thickness: i S'� HeighrAbave Ground: !�l Inches
Drive Shoe; Yes ✓ No .
Were Problems Encovntered in Setting the Casing? Yes No f �
. IC "yes" gir e rcason:
Grout: Type: N�at SandJCement / Concrete
Annulat' Space Width Tnches .
Water in Annular Space: Yes� No
_ .. Methad: Pumped � Fressure � Poured� � . �
Dep�h: From C'3 to �o F�t.
Materiats t7s�d: No. Bags Portland Cement Weight of .1 bag�Tlbs.
T.£ mixture (Sand, gravel; cuttinas) - Ratio: to
ID Plates: Yes � No� � • �
� 4 x 4 sIab Yes � No�
Z�-IERE$X CERTIFY T�IATTHE ABOwE INFORMATION YS CORRECT AND THAT
TH�S W�LL WAS CONST�2UCTED 7N ACCORDI�NC� WTTH REGULATIONS SET
FORT� $y�THE PERSON CO�Ji1T'Y HEALTH DEPARTMENT.
���_ �__
Sign [urc o( C ntractor Dacc
�
N
�
Z00'd tiZti�60 ZQ/SZ/bp SGZ6 86S 9�8 �uI 6Ulii!aQ itaM aiiauaeg
. � Person County Heaith Departrnent
Environmentai Health Section � �
T� n�Q �: A- �� � �:
Zoning: Tawnahlp: I�S�ti �r�- _
Subdhrtsion• �n�l� n.�en h y S d1, - Section: _� 3
APPiiqtiti �G K�C �� h�•.1�h w y
Locatiom ` e � Sv� �� Ge �.e'��r y
/
Qpe�ration P�ermit
System Type (In Accordance With Table Va): � - Con, �.
THIS SYSTEM HAS BEEiV INSTALLED IN COMPWINCE lAIiTH APPUCABLE NORTH
CAROLINA GENEi2AL STATUTES, RULES FaR SEINAGE TREATIIIAENT AND DISPOSAL,
�AND ALL CONDITIONS OF THE IMPR�YE�AEiNT PERMIT �AND CONSTRUCTION
AUTHO ON. �
3�z�-�el
� Authorized State Ag Date
�
�'fJo l�ouse o t- W e\� a r. Q roQec'�y �eF �
� SysT�F�, 'M�..4 -�.i ( P Y�v+na�-t�,r�� y c� k�. `C�
l
-�.� �ofiS-�
.�'� g�l1�d
1 �v� �
,�--
_�
�
. S
b� �J� �e `�.���
�
rev. 10l12199 .