A29 209� °v
. . � � � �3�,a�
Aoaiicatlon Date: � ���� � � q �� � Tax Man #• �� �
�►mount Paid: � a` �J q
Recei Parc81 #• v�� I
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APPUCATION FOR SERVICES
�
1) Permit requested b:(Owner/a er�t/prospecttve owner): i�e r►v, �` ��-� tr �a,,,1%-
Home Phone: l� ..Si�l' 35��3 Address;, `%� �3 u la�L• '� n�,- .�.'
Business Phone: b S�'�- 5/a� CQL( � . ' R 6xl+�ru '�vc, Z'1S �
2) Name and address of currerK cwnec w��c.-c. '��
3j Property Description: Lot size: �' �� Tawnshlp: Subdivision: ��"�fd S%mw rur-qLot #�
Directions to the property (Induding road names and numbets): �u � t ��!�'i S ra�,-u-�Cc �
r�z,. ,+-��u,. � c� �L �z, �� nu�tif- �..f f=,�r /f/S�..L T�.•�.,r. fA f.� wt., ti�.-
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4) . proposed Use and Structure Description: answer eact� of the foliowing questions:
a) Proposed c/ a Existing Type af Structure: S h'�� f3 lcll �C. Width: �/�d Depth: �/ o c5
��' b) Number of Becitooms: �;� Number of occxipants or people to 6e served: �
��� c) Basemec� Yes ..No ✓ Wil) there be plum b ing in t he b a s emen t? .
'. d) 6arbage Oisposak lc`ss . No �/,
:
5) Water Suppiy Type: Private ✓(new �or existing�, Public� Communiiy . Spring _
' � Are any we!!s on adjoining property? Yes_ No �tf yes, please indicate approximate locatlori on the
'site plan. �
6) Does your property car�tain previously identifled ju�isdictional wetlands? Yes_, No ✓
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPEitTY OR SRE PLAN MUST BE SUBMITTED 1NITH THIS APPL1CATiON.
➢ PROPERTY UNES AND CORNERS MUST BE CLEARLY MARi�D. -,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STA�D OR FLAGGED.
➢ THE SITE MUS'� 6E RE94DILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF. � .
I hereby make appiication.to #he Person County Health Departrnent for a site evaluation for the on-site sawage disposal
system for the above-described property. 1 agree that the contents of this application are true and represent the maximum
facifities to be placed on the property. i understand ifi the site is altered ar the intended use ct�anges, the permit shall
become invali
'/� � �� S'Z S'O
Owner
Date
PCND. rev. OB127/02
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Applicant 0.'��
�ermit Valid for
Type of Facility: .
# of Occupants �
Proposed Wastea
Proposed Repair:
Perinit Conditians:
#
� ,•
T� x.h�Ua � i. a r c-e_I �'
S•ubd!ivis�ion I ' �' ' '
h�s�e-�Sect+ian'Lot �
Iffiprovement Permit -
_ No �zpiration �
New Additiq�%� Water Suppiy ���
Projected Daily Flow _(La v g.p.d.
Type:
Type:
Owner or Legal Representa.tive Signature: -- " ' llate: ��
Authorized State Agent: vl�"C� Date: 0
The issuance of this pemiit by the Health Department in does not guarantee the issuance of other permits, It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements aze met This
Improvement Permit is subjetf 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 SewaQe Trentment and Disnosal Svstems' {15A NCAC 18A .1900). Neither Person County nor the
Environmeutal Health 5pecialist warrants that the septic tank system w�71 continue to function satisfaciorily in the future or'that
the water supply will remain potable. �
Authorization to Constract Wastewater System (Reqnired for Building Permit)
* See site plan and additional attachments (_�.
Propo ed Wastewater System:�lh?/_Uh�d[� l __ Type c� Wastewater Flow�� g.p.d.
New � Repair Expansion _ Soil LTAR: • 27� g.p.dJ ft 2
Type of Facility: . ��%� • Basement _ Yes No
Wastewatea� System Requireffients
'T�nk Size: Septic'Pank: �gai Pnmp Tank:
�rainfield: 'Y'otal Area: t 7 y� sq ft Total Length ,� ft
Trench Width � ft 1lRini�anm Soil Coves: �_ in
Distribntion: � Distribntion �oa � Serial �Distribntion
Specifications:
Authorized State Agent: �
Permit Expiratian Date:
gal Grease Trap: gal
1�Ia�mnm Trench Depth �� in
Minimum Trencli Separation: ( ft �• C.
Pressnre Manifold
The type of system pennitted is � Conventional Accepted Alternative. I accept the specifications of the
permit. __/, i%f .�. _ �� a y� 7
Owne�//�.�g�l �tepresentative: Date: „ �
,
' t^^ PCHD rev. 11/10/05
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_._ _ :, sy� �,�o� ��s�t �np�� �co�inurs onl,y. The contr�tctnr must,tlag tha systesn prior to
• 7regitaning the isistallatiun to insu� that propergmde is nrasntained :
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WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map � Parcel # d� Townslup:
Applicant: i r�f Q
Subdivision: r�r Lot # /
Location•
S• a,-E S �2 .
Type of Water Supply: � Individual
Requirements:
Community Public
Site Approved By: �
v�uting Approved By: � S /d'�7
ell Log: ��- t.w% � �vc �-N
� ,..�� P }u np Tag' r'1
�i 11 Tag:
�� �Vent:
��Io e Bib:
' g Height:
oncrete Slab:
Well Driller: ��u-�
Liner:
Installed by:
Depth set: _
Grouted:
Date:
Water Sample:
Well Approved by: ����� Q4�_ Date: n
****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 O1/27/04
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05/22/2007 12:47 336-388-5940 EVANS WELL DRILLING
PAGE 01
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Ownrr: __.�.. 1 1_.�a_—� _,1.�_�_�c- __.. Tax Map ,�,,�� E'arccl �l __�j �
L.ocat�on: �- �
Su�divisio��: �_i. i L_���,.�?�_�.13,1'�t�-�- Lqt i� 1 ..., _� ...�._...�
Wri) Con�iructfon
��i�car,�:c F'rom cxar�s� E'ruperty Line (Mtnimum 1Q tcet) �
Uiytxricc frorn Scptic Sysuecn (Miraimum 6q feei) r,,,_ `"�
7�nta1 Ucpth: .���. R Yicla; �'iPM SIs4c water Levet; �t
1�rtor Hcarin� Zonos� f�cpth ��� bS�ft � ft �--.......�__
C,�ipg:
L�e th: Frc►rr� '
F �_. �_ 3,.,.�_ tt_ Diarncccr: ._b /i1 � rs�
Type: Cialvanizcd Stcd . ✓ � �-
waight: � rh�ck�,e� �� Heiaht nbave Ground: .L �^ in
Grivc Shoc: _.� _,,... Nd A,ny �rpblema onaour►t�ad wh�l� scttm� ��si;�Q? __._Yc9 Nn
Ef"yas" g�r•e reascm: � �,.._____y__.,.....r.._. _ ....,.._.....---.._w ..__.�._._,.,._._. ^_.. -
�ronl:
Neor. _ y�ui�'Certsent L�� C'oncrcte �_ Qr�veVCemrnt
Annutar Spaca Width ��� ut;;i� y�l��r in Annular 5pacr.. �Yea �3Vv
Mc�h� of C��cyut. Yumpod __., , i'r�e�re �re.� f�tp;h _� � to ��1 Ft,
TVl�fsrl�D� iile�i; �-' ,_... _.�.
No. Bags Purclund ca�unc „ '�Vct�ht af 1 Bag _.�. i'cands
If TTkiX.tUfC (BRt1(� �(AYC�, cuti:nge; �• itatia ..,�-r,� __
Ii� platcy: �ea __` Nu 4 x 4;leb �,�Ss No
l,li�e�': -._. .
I?G;�th: _..,__..._..-_.,.� Uatc it►sr,�llcd: ,,.,,.,,_�� Grout: _ ...... _ ._ .
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lnat�;led by: _^_.._ __.�..---
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3 htrCby uertify that thc abov� infn��nstion i� eocTeet r.nci t}�at thiQ well was con_stn:,:!ed in a�cnrdgnce with r��ufatinns aet fcx:t
by thc I�arann r,'pu�ry iicalth T3cpart�r�ettt.
5i��aturC crEt:untrscltor
�F ,�,�,�� llwte .�,..:�....� .i ..�_ .' � �
i'utup ,inataliYurat
Fump Is�.ullat�on f.'ur�tr�tctor: !itrtc Rs�i�;xatic►n Nurnher•
Pump T)e�ch: .�.,._ - _ n .._. Stutic VM'�ler I.tvel. —' � � . . _.-. -,..�._ ...._,... _. �,_ ..
Pump Make & Madci: ��_ ... .� .. .... �_�.�....LT..�. � _��'cu:z�Z Six.c attid Rat�ng; h
.. . . .... F .r.____...._ idi�rn
i Etorc�Y,y cc��ity ;I�nt thin purc�p was ir�atalted and 1he wrli hcud cutnj�lct�d Recarding �o cno Ycr�n Cuunry "rV�eil r�ulas ir, r.F1'r..;c
un Thi� dale ard thae a copy of rhis racotid has bccn �u-av�dcd to t�c w�ll pwrter,
kumt� 1nai�licr SiQns�ture U�ra: . ��,
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