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A29 208' A s Itcation Date: � �� i � (oi'5� • Aena�unt Paid: ' �D � 1 s� � S . Recei t #: . VV �� `� �� Person Cauntv Health Department Environmental Health Sectlon APPLICATION FOR SERVICES Tax Mao #: Parcel #: �� S IF THE iNFORMATION IN THE APPLJCATION FOR AN IMPROVEMENT PERMIT 13 FALSIFlED. CHANGED OR THE SITE IS ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVAUD 1) Parmitrequested by (Owaerlagerrtlprospective ownerj: ��'Al�k � i!J .� . �e�:'u'� j Home Phone: 5� � q— �3 ' f3 Address: 3 0 � 1r u�fs.� ��U Business Phone: ak -U,F � 2) Name and address of carrerrt ovmer. `S a'�'� e ��`�� '`�� C �a 7 . �ed�� J, � �� t ��' � �g 3) Properiy Descriptlon: Lot siza: Townshlp: ��`'�S'��/ �G �� (5� � Direc�ions to the property Induding road names and um eB)• � 9 S �d �� a � S ��-� � +�-, � L 4) Proposed Use and Structure Description: answer each of the following questions: a) Proposed�Existinng � b) Stldc Buiit 0, Moduiar 0, Single Wide 0, Double wd� c) Number of Bedcnoms: �, - � Number of occupants or people to be served: e) Basemerrt Yes �, No�f yes, # of basement fndures: fl Garbage Disposal: Yes �, No ❑ 9) Dimensions of Proposed Stnu�ure: Wldth: � Depth: �� Water 3uQpiy Type: Private �(new 0 or e�ds�ng 0), Public 0, Community D, Spring ❑ �. Are any wells on adjoining property? Yes ❑ No � If yes, bcatlon 6) Ptease Indic�te Desired System Type: (sysfiems can be ranked in order of your preference) ,�, Cornrerrtionai TModifled Converrtlonal _ Altemathre _Innovative Other (specifY): CLEARLY STAKE ALL CORNERS AND L1NES OF THE PROPERTY. STAKE THE CORNERS OF ALL PROPOSED STRUCTURES. Pl.EASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPUCATION I hereby make application to the Perso� Caunty Health Department for a site evaluatlon for the on-site sewage disposal system for the above-described property. I agree that the contenb of this appllcation are true and represerrt the maximum fac�lities to be placed on the property. I understand if the site is altered or the irrtended use changes. the permit shal! become invalid. I understand that as appGcant, I am responsible for identlfying and marking property lines, comers and making the site accessible fo� the personnel of the Person Courrty Heaith Department to condud their evaluations. I understand that I am responsible for notifying the Health Departrnecrt if my property contains any wetiands as designated by the Army Corps of Engineers. Owner Legal Representative q_/,�-�G' Date PCHD, rev. �a��ss .. . � , � . ' . . PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAYOUT Tax Nap �k l�aq �a� � o '� Zoning — Township cf7 � S i rc�rl � „�P„�„n; Fr'an K I i n c � � p� LOCefIOrt: � J L' t! %� DA h. Q li I K 0� h /� r C C� l�d suwstwswn: �ru� Ic I i n OCn II V s.a�o�: � S O�. 3i�' m i�e bcsrd � eemc-��r Improvement Permit A buildin� pennit cannot be issued with oniv an Imorovement Pennft New„X Repair _ Addfion _ Type of Struc3ure ii1� Water Supply �f rl UCii�- �"�� '. # of Occupants l�/►►aX # of Bedrooms � Other__ - BasemenYt ,��Basement Flxhires?� • Projeded Daily Flow� g.p.d. Permit Valid For. �'�,Five Years 0 No Expir�t ��.90 `Redu-��,.an 5 yS��i''� ProposedWastewater�SysteniT pe: �ra,u,'t� ZnnOUu.�'uc �n;t,;a� � R�P�-``" Pump Required? Yes �No ed o� lo� hy ��5 Permit .� �Ta Owner or Legai Autho�ized State Agen� �1 %'oA�So �' 1 �or ac�di�i�ana,l �,1� �. /2c�w �'c r� i ��a � sY,s� . oete• • � - U ° Date: �J � � � The issuance of thls pertnit b�the Health Departmer�t in no way guarantees the Issuance of other permits. The Permit hoider is responsibls for checking with appropRele goveming bod'ies In maeting their requlrements. This � site is subject to revocation if the slte pian� plat� or fhe intended use cha�nges. The Improvement Pertnit shall not be affected by a change in ownership of the atte. This permit la subJect to compliance wtth the provfsions of the Laws and Rules for Sewage Treatment and Disposal Systems of tt�e North Caroiina Administrative Code. Authorization To Construct Wastewater Svstem (Required for Build(ns� Permit) Type of Wastewater Sy�m ��a��'� Sn�c� �Q�l ��Wastewater Ffow: V�i� a�.p.d. • Fadlity Type: 0 C i�OIriG . New�B'. Repair OExpanslon ❑ Basement? 0 Yes No Basernent Fb�ures? 0 Yes �i,No {,LUa��water 8vstem Reauiremerrts Septic Tank Size: �� gaUons Pump Tank Size: ��A gallons �Total Trench Length: � feet Maximum Trench Depth: � inches Aggregate Depth�� In. n�� /11 �hlt(►► I ' fmam Soii Cover. l� inches Trench Separation: Feet on CeMer . other. Ke��sY,4�LM Oil C0� "�bu�j -I � bn ec�.tc r, (� � fo l��S F��n` cJUI � PeRnit E�iration Date: r �� a�� S Authorized Stete Agent: ` Date: I a—, —�C7 The type of system pe d O does ❑ doss not differ from the type specified on the applicatlon: i accept the spec(flcatlons of this pertnit � OwneNLegal Representative Stgnature: _ Dabe: '� �` d� PCHD, rev/ 10f12/99 � � FranKfi� Oenn � Application #: � Tax Map #: k� Parcet #: ` 0�_ Person County Health Department Environmenta! Health Section Name Authorized State Agent SITE SKETCH FranlCli� Denn� S SubdivisioNSection/Lot# la - �- �� Date System components represent appraxrmate contvurs on1y. The contrwctor must}lag the system prlor to beginning the installatinn to insure that proper;�rade is maintained � ts q�. t33 �` - � Scale: - � , . �ys p �95� c � �� . p �� Z��, $ � �3q=s�{ � / Es� � I ' i ct�i � I7st�l �S' oo � �� . , oo.- . a ��• � t / l�t� �0'7o P/L t ,� --� 6 , 6 �s" r— — — .— � �f�' - � , K � l$ VoQ��'h , �S i�` �o' .. �1■ ,�$. r �/L 95•5"T' ►o C,�,�-��c�o � �ay nced :'- � 1av►d c rn ��ads dF 7opsai I �o� addi�ao�.( co�er oF �J_ PCHD, rav. 10/12199 F' � � � ' PERSON COUNTY ENVIRONMENTAL HEALTH '. PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT T.��: �a� P�� a o� Township �c�5� v Fo r k Zoning . ,,�P„�,,,� �t'an K I i n D e n n v� - �� _'' ��rc 2oad Lccatlon:�Ly � � . � � Subdivisian• �ra✓� Kl i n Du1ns/ s��• �� `_ Weil Permit T e of Water Su I: �ndividual Community Public Reauirements• Site Approved by � S' /—i1�-- o/ Grouting Approved by � � _ / �-�� Weli Log - � o� Well Tag Air Vent Hose Bib Concrete Slab �i ur�-p� �c. tc�� v`� Well Drill�t: Well Approved By: �"�- �� Date:�� c�'� **See Athached Site Sketch** Welis must be 10 feet from property lines. Wells must be 100 feet ftom septic systems. Wells must be �at least 25 feet from any building foundation. Other conditions:� c.ep �1GcXimu�n l�Oc.�ab l��d �stct�.ce, F�om �eAL1c c PCHD, rev. 11/29l99 PERSON COUNTY ENVIRONMENTAL HEALTH WELL LOG Date: - -� � � Owner. �f� n k li, Location/Directions: SR# Subdivision �Name: ��►X ,'� � � ,�•� Lot # S� Drilling Contractor: � � �� WELI. CONSTRUC'I'ION Distance from Nearest Properry Line ! v Distance from Source of Pollution ( G � Total.Dep.th: ,2.6o Ft. Yield: � GPM Static Water Level aS' F� Water Bearing Zones: Depth 1 4 F[.��t� F� �t. Casing: Dep t h: From 6 t o C�l� F t. D i a mete r: I n c he s TYPE: Steel � Galvanized Steel If Steel, does owner approve: Y�s 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 A�ular Space: Yes No _ .. Method: Pumped - Pr:ssure � Poured � � - � � � Depth: Fr�m O to �, O Ft. Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs. If mixtule (sand, gravel; cuttings) - 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 WITH REGULATIONS SET FORTH BY-THE PERSON C�Li�TY HEALTH DEPARTM �� - �a/ � _. _ 'gn [ure oE Co ractor Datc . � ��saora ��t�a�� eipa�ea� � � �� o� a�� _ �� %ing; � Tawna�d� • � SubdWl�o� Sedton: _ Lmt _ �4P� Rvt'�� i 1.�tton: ' . � C� e�r�ation Pe�'r�l[t +� � . . �' Syst�m Type (In Acxardanr.� W�h Tabie Va): . THIS SYSTE�A HAS BE'E�+1 iNSTALLE� tN G�MPLIANC� VVITi1� APPtiCABIE NORTH� � - CAi�O�,lN�1 G1E�IE�AL STATUTES, RULES FaR SElIVAG� TREATNE�►IT AND D15POSAL, � .AND �ALL C�NDITIONS OF THE 11APROV6IA�'i' P�IT �AND CaNSTRUC'TiON � AUi'HO ON. � . � �' ��C � � . Nt � � - � � st�e,��nt � � �,�� S�� c� . . , _� � - . PC�iD, ,rev. �0J1aJss .