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Person Countv Heatth Deaartment
Emrironmenta! Health Sedion
Tax Mao #: � � �
' APPUCA'TlON FOR SE�tVEC�S �
IF THE INFORMAT►ON IN THE APPUCATION FOR AN IMPROV61AEiNT PERIIIIT 19 FALStFiED. CliANGED. OR THE 3Cf'� 13
ALT'EliED TH@l THE iMPROVENEirT PERMIT AND AUTHORIZATION TO t�N3TRUCT 3HALL BE�OME iNYALfD
1) Aemdt nbqc�ested by: (Ow erlagentlproa�eclive awnerj: i ��� �
Homs Phona - 3l0 - 5�.� Addreax - % u k� �,=i ,�/Ta/. .
Busir�s Pttpte: - - afp03 ) i1�m��. /F/�r. NG �'75"�"3
. 502�- lo8a�"Ser _ . � 1 �
z) i�an�s and �ddr� oi c�rr�ent owrnsr: a � ,� �oh %� . G�rch� . C0.
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� PrvPertY De�tlon: �at st� I U[�c,Ta�c '�u S,� � rk O IU S i�-�_
�tredtor�s to a�e property (tru�udte�g ra�c! r�atr� an�i nwrd�prs): ,,/SlS� 7ahN /�//en /Z� _ .
4) Proposed Uas and Struct�ue Desqiptlon: answe� each of the foUawin9 �
bj s��`�o, � a. str�tewwe a, oo�e wtde �' C 3►-� �idd ��i a.�-�
c) Nurtuber of Bedrooma: � . . � Numbet of oa:upants or people tc be seNe�
e) Basement Yes Q No �If"yes, � of basemant �dtuex
� Gerbape Dtsposal: Yes q Nc C�l/�
� D6ne�ans of Propoaed Stnx�e: W(dth: � �epdh: � •
���PWY TYP�: Priwate �ew �'or eods�n9 �. PubHc q C�nmuniiy 4 Sprin9 �
� Ara arry welts on a�oining prope�iy�T Yas ❑ No 0 If yes. loc�ion
� Pleass indicabe Dsdred 3ystem "tyPe: (aYamms can be raniced in order cf your prefenncsj
�Car�wntiorwi �Mo�ied Comerrtiona! _ A�ILe�natwe Innovative
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CLPARl.Y STAl� ALL CORNERS AND LWES OF THE PROPERTY.
3TAKE THE CORNEiiS OE ALL PROPOSED STRUCTURES.
PLEASE ATfACi�! SURVEY PlJ�T OR SlTE PLAN TO THI9 APPl1CA710N
I hereby make appiicatlon� to the Person CauMy Heaith Departmerrt for a sitee evaluatlo� for the on-sibe sewage dispasai system fior
the above-descxitied prnperiy. f agree thst the conteMs of this appiIcation are true and represent the maxirtuun faci�ea to be
placed on tha properiy. I understand if the s�e is aiEered or the irttended use d�anges. the permit shail become irnreltd. I u�and
that as a�p8cant, 1 am rasponaibie for ide�ying and matidn9 P�P�h► Gnes. comers and meldng the �te a�ibM fiw' the
P�nne! of the Person Cotmty Heaitlt DeQsrtment to c�dud their evaluaHona I understand that i am respor�le for not�ying the
�� ��S► ProP�h► carttains atry wetlands ag designated bll ��Y �� ��� .
� .� ` � � r�o�-od .
�a . owner or t.egal Represer�ve . Dale -
PCfiD. rav 10M?J99
��#�St31V Gt�l9ivT't E�1V1R�N1{AE�TAL �E�ALT�i
',���Ei� ��6V �t�R St�IL AR�A AN� S�(S�1AA L
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� Improvement Perini� � .
� A building �ermit cannot be issued with aniv an lmarovemerrt Psnnit
• New �� Repair � Type af Strudiue SFD � Water Supply � .
# of Occupants ,� #•af Bedrooms � Other
� 8asemettt't ��, 9aserner�t Fcduc�es? �_ .
Projeded Da�1y Flow: ��f3 g.p.d Peim� Valid �: j�Five Y�rs 0 No ExpiraUon
��/1�3S�iAf�C � ��il n o u'cc �t i v L .
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ProQased Repair :.i h v �.f- ,�`v ,� � n I (� n (.}
peftnt�COI1�IOi1S: SrA,�t �0� 1+-- OYUPP,f'IN �1/1G, � Xroi�n i�tlt�Gl�vtA -#auv.dAli
hovP �'��o.�.eu,� a
Owner or Legal Rep�ve
Autl�orized State Agert�
•tCi� . -�-����•I� s.:.l Ova�P�f
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The issuance af this perrnit hy the Heatt� Departrnent It�.�o waY 9ctaraMees the issuance of ottta p�tuis. The perrn�
holder is respons�le for ct�edcir►g with appropciate goveming bodies in meeting theic require�nents_ This sibe is
subject bo revacation if the stte plan, pla� vr the irttsnded use changeet. Tha ImQroveme� Pem�it shail not be
affected by a cl�ange in owna�hip ef the aibe. This permit ts subjec! tv camplianca wlth the provisioRs of the
Laws and Ruies far Sewage Tneattnerit ar�d Oisposal Sysbems of tlte North Caroiina Adminlstrative Code.
Aathorization To Construct Wastewater Svstem (Reouifed for Bui[din4 Permitl
Type af Wastev�rater Sysflem Sx n 0 v� i � P WasteuvaLet Fiow �" � a,�.d.
Fac�iity Type: Z�7� �5 ��C 2� 1 i� New/� Repair pExpansion Q
Basemer�Ct 0 Yes �o Basemerrt Fahues? I] Yea� No
Wastewater Syatem Reauiremenb ' ' - • '
-. Sepl� Ta�lc Size: f D � 0 gaaons Pump TaNc Size: / D 6 0 gaQons
Total Trend� Length: Z`� 0 feet Ma�dmum Trend� Deptk I� incttes Ayg�aba Oeptk u�
Maximum Soil Cover: � inc�es Tr�eru�t SeQar�On: ! Feet � C�
� �tt�er: �b h Qc(ct�"i�0�n, l s �� C��Br �2���'ec-� o �er sep�c
_ �ue . `f s�o�e �--
Pe�mit Expiratian Qate: ' � -
Auiharized State Age� Da�: '�' Z�J ' o( •
The type uf syst�n permitted Q daes Q do not. dif(er fcom the type specified on the applicatian. I acss�pt
the speraficatta�s of this permit
Owner/Lega1 Represer�tative S1grt�re: p�: ,� � Z l�'!1 �2/ .
• PCND, re+r.1'1/18l99
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P�es�n �aunt� �:ealtta. i3epardment
�vir�nmenia� Hesltl� � Seciior�
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,S�,�n ca�ppxe� p�presp�t Qppr,pud�e cs�rQs o�tly. T�te carrdwctor �trr�t,Jtag the �yys�eei
�. prior m b �it tbe in�a�oa to i�ure that pmpe�'� �s �
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PE3�SON COUNTY F�IVIRONME�iTJs►1. HEAL• TH
PtF,4SE SE� ATTACHED PlAN FaR WELL SiTE t�YOUT
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� Weil Permit � . .
Tvae of Water Suaah►: �nd'nriduai CommuruiY . Pubtic
ReauiremeMs: _
Site Appco�ed by � �
Groufii�g A�raved by. � - Q- �
Well Lag �/
Weq T ' �
Air Verit � -
Hose Bib
Cocicxete Stab
We11 Drillec: �� . .
Well Approved By: �� -
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*''See /ktfacfied Sifie Skefi�ch**
� Wells must be 10 feet from prope�tY lines• �( ,
Welis must be�eet from septic systems. .'�'^"' `'`--
Welts must be at feast 25 feet from any building foWndation.
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Other co�di�ons: � �
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PCHO, rev. 1'IIZ9/99
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Well Log
Owner: %,�•.rr�f �j ��� /�,�j��"/� Tax Map ,aU% Pazcel #
Location: � t !j�/.,�.� .{-
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Subdivision: " " Lot #
Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from Septic System (Minimum 60 feet)
Total Depth: I�f� ft Yield: GPM Static Water Level: ��'� ft
Water Bearing Zones: Depth/� � ft ft ft ft
Casing:
Depth: From �j to �is ft. Diameter: � in
Type: Galvanized Steel ✓
Weight: Thiclrness: ,(�� Height above Ground: in
Drive Shoe: ;/ Yes No Any problems encountered while setting casing? Yes No
If "yes" give reason:
Grout:
Neat: Sand/Cement Concrete GraveUCement
Annular Space Width inches Water in Annular Space Yes No
Method of Grout: Pumped Pressure Poured Depth to F�
Materials Used:
No. Bags Portland cement Weight of 1 Bag Pounds
If mixture (sand, gravel, cuttings) — Ratio to
ID plates: Yes No 4 x 4 slab _ Yes _ No
Drilling Log . Location Drawing
From To Formation
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I hereby certify that the above information is correct and that this well was constructed in accordance with reguiations
set forth by the Person County Health Departm
Signature of Contractor � �C� ID # �0�-�-/ Date � � > (o -�'� �
PCHD rev O1/16/02
. . Poc�on Cau�iJ H�ifh �r�rt � .
�:avirama�antai R�i�a Sedion� � �
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� Sjl�Ct Type (in Aa� Vl�h Tabie Va): �
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TtBS SYSTEY kU�S BEH�t Q�{97'AL1PD !N COMPt1ANC� 1NI1'li APPLIGABL.E NOitfH
CAROLWA GENBiAL STATUTES, RULES FOR SEINAGE TREA'i11�NT AND DISPOSAL;
.AND CONDiTfON9 OF 7HE i1NPRWBIEM' P6ilp7 �AND CONSTRtJCT10N
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