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Ap�licafion• nate: � .. 1 .
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Pendt requa�ec�l „�:�(_ �rh9�!'Pros�►e� ��: SO �1 � � • ��`N � � �o'� .
Hcma Phone. �
Business Phon� " . o X 0 �r � til
Waaae and addnas oi carr� ownac: �'e-1�1r' E. �..��n ��T( e�`
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.
.For� :
3) Praperty 0'es�i�Etan: Lot siza a" Ta+nrrrehip: �u �`y Subdivision• Lat�:
Dtrec��s to ths tu+oPeKj! 4lndudin�raad.names a�d�numbers): -� 9--5 ���-
4)
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Proposed U� anc�.�uctur� Descripfiton: answ� � ot the foilowfig qu�on� .
a) Proposed ✓ F�Stin9 �, 7`YPB of Strudu�+e: - N-o � SA IA�dtfx. [�ep�:
b) Number of Bedtoor� .�,,,,3_ Numb� of cccupani� ar people bo be s-erv� '
c) Ba�nen� Yes ✓, No _IAdU t�-�ae �S in the basemeM"� '.
d) Gerb�e Dl�k Yes _, Nc .
�►�' �+PP�Y �P� Privabe �� (c�w _ ar e�g ,�. Pu�c_, �am�r�u�itY _.. SP� ,
Are•eny u+ells � adjoinir�9 P�'hf? Yes,_ No _ ltyes� piesse it�e appr�fie Icc�Ion cn the s�e �an.
8j Does the p�o�cly �tain pteviowiy � jur�na! �? Yes _ Ato _
PLEA�E NOTE TNE FOLLOWING: ,
'➢ A PLAT AF'iF� PRCP�iiTY OR SIiE Pt�IN 11ft1S4 81E SllBii[TfF,� UII'fi� THl3 APPUCATION:
� PROPEit7Y LINES AND COR�S �IST HE CLEARLY Yp1Rd�ED. .
➢. THE �DPC9� LOCATl�N OF ALL 9TRUCTURES �i119T HE STAI� OR AAG�. • .
D THE SifE �It1ST BE READtLY A�16LE FOR AAl E1/ALUAT�N BY THE HE�LTH DE�!►RTBI@li' STAFir.
�
I- here�yf m� a�lic�cn tn the Person Cowrty H�tth De�ent for a s�e e`reiva�On fnr the ots-�i�e sewage disposa!
system for tfie abave-desc�bed property. 1 that the contents af this a�ppQc�tion are true and re�r� the maadmum
f�ities tc tie p an the PropertY. ifi �s altesed ar the i�t�nded u� changes, the permii shail
becattte in�alid. � . , �., ,�_ � /'
or Legai
3-13 -��
Date
p�-}p, �su 10f17/0'1
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�gn.lvn�t-���xn.��n.��.� ����m.Il��.
Applicant:
Location:
d
Ta�x M�E� ' - R P�rcel # -
�Sirl�c�'ivis�ion
Ph��se Sect�ion Lot ?
f c�
Improvement Permit
Permit Valid for �e Years No Ezpiration �� �
Type of Facility: . New V Addition Water Supply ��
# of Occupants �# f Bedrooms Projected Daily Flow _� g.p.d.
Proposed Wastewater System: (�(,1, v- • Type: `�
Proposed Repair: CgM,�/� � Type: �
Owner or Legal Representative S' ture: �� /�� --" Date: ���"a- aa—
Authorized State Agent: Date: �— (�( � 2
The issuance of this permit by the Health Department in does not guazantee the issuance of other permits. It is the responsibility of the
applicandproperty owner to in sure that all Peraon County Planning and Zoning and Building Inspections requirements are met. This
Improvement Perinit Is subject to revocatton�if the slte 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 compllance wIth the provisIons of the North Carolina 'Laws and
Rules for Sewage Treatment and Dtsposal Systems' (15A NCAC 18A .1900).
�' Authorization to Construct Wastewater System �Required for Building Permit) �
* See site plan and additional attachments (_)
Proposed astewater System:_����iY1(?�l � Type � Wastewater Flow (�g.p.d. _
�v
New Repair Expansion _ Soil LTAR: � c� g.p.d./ ft 2
Type of Facility: � Basement Yes No
�'Z^c „ -
� � /� O M �1
Wastewater System Requirements
Tank Size: Septic Tank: � gal Pump Tank: gal Grease Trap: gal
Drainfield: Total Area: �a.Q10 sq ft Total Length � ft Maximum Trench Depth o�t� in
Trench Width � ft Minimum Soil Cover: � in
Distribution: \/ Distribution Box Serial Distribution
Specifications:
Authorized State Agent:
Permit Exnira ion Date:
�
Minimum Trench Separation: � ft
Pressure Manifold
Date: �'� � �'� Z-'
The type of system permitted is � Conventional Innovative Alternative. I accept the specifications of
the permit. yy�
Owner/Legal Representative: , / ' ��'� �'� Date: .S o�oZ �a"
Operation Permit
System Type (in accordance with Table Va) •
The system has been installed in compliance with applicable North Carolina General Statute, Laws and Rules for Sewage Treatment and
Disposal, and all conditions of the Improvement Permit and Construction Authorization. Iasuance of this permit does not guarantee that the
wastewater aystem will function properly for any given period of time.
Authorized State Agent:
Date:
PCHD rev. O1/23/02
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-�- � �� ��T� �Y
7E��s-�� � ���.�.11 7L-�T��.Il�I�
Name '�'
Subdivision —j
�
Authorized Sta.te Agent
SITE SK�TCH
t
Tax Ma.p # �� Pascel # � �
Secti.on/Lot#
.� Z
Date
System components represent approximate �contours only. The contractor must, flag the system prior to
beginning the installation to insure that j�roj�ergrade is maintained
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s�ale: � Q.
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PGHD, rev. 09/12/01
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I���a�-�������.I! IC-3L�.�.IlvE1�.
WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Ma #: ��� Pazcel # �` � Township
P
Applicant:
L�
Subdivision: Section: Lot:
Location•
� � � �1�� ��.✓
T�e of Water Su��ly:
Rec�.uirements•
Site Approved by
�C Well Log " � �
Well Ta
Air Vent
Hose Bib v
Concrete Slab
C��
� IndiPidual
�
Community Public
Well Driller. ��i(�„u �7
Well Approved Date: � ��
'�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 anp building foundation.
Other conditions• �
PCHD, rev. 09/07/01
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IE�.�a-���� ���.11 IE3L��.71¢1�.
Applicant:
Location:
(.t,✓ti
T��x Nl��p � � F�rc�el r -
S��,bd!ivis�io�i
Ph��se Sec�t+ioi� Lot r
�
Operation Permit �
System Type (In Accordance With Table Va): .��
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE lNITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTiON
AUTHORIZA 1 .
;�
_
: . w�, _ �. . . . � ��a�� � .
A horized State Agent Date -
.
, . r � p�
instalied By:�o� � �1,� �-�� Date: D � � �`'� �
... . . .. .. . . _ . - � -�� �-
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S «'�L
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� PCHD, rev. 07/29/02 � �
�
: � p,�•
q SE��1C �'AN�C �NS�E�CT1�N C�iE��4.1ST (Zi'ype il - Il/�
Tax MaQ # �G � ( �arce! # � f � Systern Type (Table Va)
Owner/Applicant Subdivision
Address/Location SeclPhase Lot #
Septic Tank n� a ate �tn cat�on nes n�tia ate
State ID/date 5��`�� � �fZ- ✓ Trench Width 3 ft. f
Capaciiy, d Uv. gal. Trench. De th iti. ��
Tee and Flter ,/' Trench Length � a� ft. �/
Baffle Trench Grade �
Sealarrt � � Trench Spacing c/'
Riser if applicable Rocic Depth and Quality
Tank Ou�et�:Seai Dams/Ste downs etc.
Permanent Maricer Pressure Laterals ^
Pump Tank ,.. Hole Spacing --
tate ate � . o e ize —
Capaciiy � gal: Pipe Sleeve `
Waterproof /Sealant . Tum-ups/Protectors �
� Riser Required Setbacics
Water Tight From Wells �. � �f
Pump -- � From Property lines
Check Valve/Gate Valve. : .. .. . ..._. _.._ __ Structures/Basements _
Anti-s� on o e -: . .-� itc , es rainage ays
Fioats/Switches .. . _ . . ... _ . _ .. . .. � ___ . . _ , .. Surface Waters . . _ .
Alarm visable and audible Public Water Sup lies
Electrical Components Vertical Cuts >2 ft.
Rate gpm Water Lines
Approved Pump Modei Vehicle Traffic
Blocic Under Pump � Adjac t�Systems
Pump Removal Rope/Chain Easements/Ri ht of Ways .
Distribution System Other
Serial Distribution ' Easements Recorded .
ressure an� o d e perator ontract
Low Pressure Pipe • Tri-Partate Agreement
Appr. Pipe Material and Grade -
Vaives -
Comments� �
pct�d rev. 3/13/01
10/18/20Q2 14:24 336-388-5940
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I��ra�•maz-�azrs..sracn.�c�ara.,G.�JL 1E�3I�.er►.I11i:ll:a.
Own,er:
Location:
Subdivision:
EvAraS wELL DRILLING
4
Dri�ller IO # i,
Com�:�ny Namc? „
O�,t�e Dri.l�led "
Weli I�o ;
Lot #
�r� ��� g.�� P
Wcll Constructioa�
Distance Ftom nearest ��operty L�it�e {�iu�i.z�uw� lU ��) �
Distanee from Septic System. (Iv�izzimum 60 zcct)
Totai De�th: �6 p ft Xield: S' G�'M Stauc W�tcz Level: �_ ft
Water Bea,ring Zones: Depth Ft ft [t �
Casing:
Depth: Fram, G} to �� i�. Diametcx: � ira
Ty,pe: Galvawiacd Steel .i- �
Weight: �____ Thickncss: �� Height above Ground: ►�,T iz�
Arive Shoc: Yes No ,A,xay pcobiems er�cou�ntcrc;d wkuiic settinb casxn�? �
If "yes" give reason:
Grout:
Neat: Sand/Cement � ✓ Conc;rete GraveUCemc�t
Annular Space Widd� _,^__��____ inchcs Watc:r in �1.mjaul�u- Spac�i _
N�ecb�od of Grout; Pumped �'zessurc �'1'owred D�pch
Materials Uscd:
No. Hags Po�tland c�m�nt Weibht of ! Bag �„� Pottnds
i� rm.ixture (sand, ga�el, cuttings) — Itatia _� to �
ID plates: -!Yes � No 4 x 4 slab ✓Yc;s ,� No
From, � To
Drilli,nb Log
v
Z bereby eerdfy that rhe above informacion is corre�t and that this well was coz�scru�ted i
e
set �'orth by the Person County Health cp�c;nt.
Sig�aturc of Co,�txactox ZA # a �, i Da�
✓ iV 4
�--�'� No
to �t.
�
with regulations
F'CHD rev OU14142