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A29 215Aonitcatlon oatx� � l I- I- 00 ,�d� �d:.�._3�a— �.� � c�-� � �, � � � ' �-- �aa�.o . 3' � 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. s n �cn o�. �, S, -�-� � e e.�— � 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 —� �sP��l)� � �� � �� �s�� �� � 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 , q �� z.►� . . � . � T�� iA 5 . r ; � s �o►�a�.o„� r�t�-.. v h y � �a�an ��h � . � � � 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 . %� 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 �5' ow�� (�,, n`four � � 3-Lf-dv . p2te; � - o� 1 - D � 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 ..� � P�es�n �aunt� �:ealtta. i3epardment �vir�nmenia� Hesltl� � Seciior� � r. � ' • . . ..- � � - / % //� : fr����'' �� • I�_.� r_ tc 'f•�' � T'ax�l�agi �: � � / P�ai �: � . . SvbdivisioNSedicnlLut# 1_�-�_�l . Da�e . . ,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 � � Zdo X 3' ��►^o,�o� 1ve ��� sys r��- �Lao ?C 3� ��. � o �a`�i �e � p�. t— Y _ eLL +'��E/��� � S'e�3�2 a.,� �,,��.� �nks C�e.a�kou�' Sc�le: / �' = � � �r M � -�ns� �� �" pr��� �aYa�e --�p l�� Cvi n� �d n( 0 cir, �' � �/� y�.� Yj[t,l Icl��d� �+.t►�tRl (d�'t � rD � �,,� �vnj�e�c� (�►�a-� � � � �� a� � � + � �-,,.�,;, � ; �eqt��c�� oV'e,� se��c D �ue —�'fl Slo�2 �,� i �' a �.,�- �o�i c�wt . av�c� dra.iy.a,�c �;i-c� V �--- s���� � �� (�, �� �-o�,f -- �� ��,�; �a���.rt�,l N�.E�-�, ��;���t � /���,� r t�r��- Covei' � �re� � .� ` ' PE3�SON COUNTY F�IVIRONME�iTJs►1. HEAL• TH PtF,4SE SE� ATTACHED PlAN FaR WELL SiTE t�YOUT ��� � �� a `� � �¢ � • T� L Y� Zoaiap • „� ,%�r� jl 1/1%i!1 r °� �ns' - � . - � � �: � ,,� . '.°�- _ � 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: �� - . �. �'�-��- *''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. R � Other co�di�ons: � � a � � i : �'ye � PCHO, rev. 1'IIZ9/99 ��� �� ���� �� � �D � .?t��-U I � 1 • �/ � ��� � � � � l.�.yf//i �C� vV �/ / .,L!/Jt. ���a-��,r,�, ��.��.a ���.a�� Do �- D��l �- � �, -0'1 Well Log Owner: %,�•.rr�f �j ��� /�,�j��"/� Tax Map ,aU% Pazcel # Location: � t !j�/.,�.� .{- � d/s i/� ���.� �x ty�.� 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 J� 'r �j�nr G� % C7 �� Gc T � �f,�r fq�"���1 �-�/J. Lt� ��� �� . � �� � � o ��D 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� � � . Taac i� � �ea! � _ � f� . � . .8�l0� L.o� � ���-t' 1� � � �l� ,4 a�+o � . - �. � � � . � � � �pe�ration �:Permi�t � � Sjl�Ct Type (in Aa� Vl�h Tabie Va): � . . .. , 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 � 3 ��-fl � � . ��� . . � . µ 1 - ��pZao z -�. � o c o s�-a - 3 � f��rrtG ���-ZI�Z� I 'Pi'��- i D o O . {'�- - �S� . . ���Z �°�' � . . Z ��Dero,o�,,, , 9 . � ' ' � . � � 9 �� �� •. . 1Z j" h A" � (O �f �2�� � . ;,,��e� � . . �- . 2�%L/� 2 - iNg�o� c-�p � ��� • . • �' : � . ��r'N L%r'�� �. � � Coa��z�w�