A29 219Amo,unt paid , TO
•Receipt"• �� �
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1, permit requested by: .
�.vnPr/nrnSDeC[IYe OWIICI
ress:
ome Phone #: �`�� ' ��' ��—
usiness Phone #: -
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Name and addre�s of,current owner:
�
. Property llescn
. Tax Map#:
Parcel#:
Township: � -: �
� '2�5�3
:ion: Lot size: _
29 - Qo
_ � � _�„�t
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7. Dimensions or Proposed Structure:
Width: I�
8. What type (if any, additions, expansions, or I
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
I �
9. Watersupply type:
_ private �j . public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes Q No j�
If so, identify location:
. Directions to property: State Road #& Road
iames,�tc.
i-�_R�1� 11 �l�
10. Type of structurelfacility: Proposed: C'�Existing: Q
ype of dwelling:
House: ❑ Mobile Home: C�Business: ❑
Type of business: ,
Number of Employees
Number of bedrooms: `—
� Garbage Disposal? Yes ❑ No Q�
- Basement? Yes❑ No�If so, # of basement fixtures:
6. Number of occupants or people to be served: .�-- pROPERTY AND THE CORNERS OF ALL
CLEARLY STAKE ALL COR ROPOSED S RUCTURES• �
I hereb make application to the Pet'SOn COunty Health Depal'tment for a of th s auali� tf on ahe �e ite
Y
sewage disposal system for the above described property. I agree that the contents P
and represent the maximum facilities to be placed on the property• I und before ntlmprovements Permht an be
intended use changes, the permit shall become invalid. I understand that
issued, I must present a survey plat of the proper[y to the Health Dept. I und ite chetdate ofhhe evaluah oneof t
delivered a survey plat of the property to the Health Dept. within 60 DAYS a
the site by the Health Dept., this application shall become void and all fees paid forfeited.
SiQn Owner or Authorized Agent
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� � PERSON COUNTY HEALTH DEPARTMENT
� WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
B 2467
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shali be issued until Authorization for waste water system construction
has been issued.
Tax Map # � �� Parcel # �1
Zoning Township �
Owner/Contractor
Location/Address
� � , �.� ( �,., .L
ivision Name
�
' Date —
►
S.R.#
Lot#
SEWAGE SYSTEM SPECIFICATIONS
pair Lot Area�j,�j ,4� Size of Tank_��
D �/ - Mobile Home ✓ Size of Pump Tank_
siness # of Bedrooms Z Nitrification Line�
Max Depth Trenches
� �--� 1'7� ���
Permits may 6e voided '''s altered or iritend^ed �e
Well and Sentic Lavout b��_ J �S1(
`x��_
? � � .�'7,-, �l
�-�l � o � ` � . A.��.._-,_���� �un .��—� �
Date 1 � �3 -gg Installed by ���. ` Approved by �il/..�� .6 �r�,a,�
la�,�- ��-ia-9 �
ell Permit Paid WELL SY5TEM SPECIFICATIONS
Individual �� Semi-Public Required Slab
Public Replacement Air Vent `� �,,
Site Approved
Well Head Approved
� j Grouting Approved_
� �j Comments: C
Date
Installed by.
Required Well Log
Well Tag
n.� _
Approved by
This report is based in part on information provided the homeowner or his/her
representative in the appli�ation submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The environmental health specialist is also not
responsible for concealed conditions on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. Neither Person County nor the environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
\
'1L.
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
.
, . (Void sixty (60) months from date of issuance)
'DATE: - d- 9 IlVIPROVEMENT PERNIIT #: �o��
TAX MAP #: /� o2-�I PARCEL #: � �
OWNER/OWNER'S REPRESENTATIVE: ��� 1�tI f �� �
LOCATION/ADDRESS:
SUBDIVISION NAME:
SECTION OR BLOCK:
AUTHORIZATION
�
ISSUED BY:
AUTHORIZATION CONDITIONS
LOT #:
1. The Wastewater system construction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Pernut #-�a��. The
construction and installation must also meet all applicable niles and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any alterations in site or soil conditions (including structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authorization and associated permits.
4. Conditions:
Person Requesting:
�
0
P�RSON COUNTY ENVIRONMENTAL H�AL'1'H
�JELL LOG
Date: � ' � '`� � �.p � �T'Q�TU Q (aNGE�Q l�cJ[�EN� SR# - .
Owne:.
i,ocatior./Directions: � .
L�t �
Subdivision Name: ,. , ,���� „mnn S � � -
Drilling Contractor: _ �,�T � �ON�'RL��ON
Distancc firom Ncarest�'roperry Linc
D�stancc from Source of
Pollution � Y2 GPM Static Water Level F�
Total Depxh: � F� Yield: • F�+ �t.
Wacer $ea.�ing Zones: Depth Ft._.___..Ft.
Q o- (`� Ft Diameter: � Inches
Casing: Depth: From______._ G�� Steel_ '�
TYPE: Steel '
If Steel, does owner approve: Yes N0- Inches
Weigh� Thickness: • ' Height Above Ground:______
T?rivc Shoe: Ycs No _ • - ----
Were Problems Encountered in SettinS the C�'ng? Y�s-+----' No""""_
Ii "ycs" givc rcason: Concrete
Crout: Type: Neat _ Sand/Cement_
Annulu. S�aca Width_ ches
Water in AYu►u]ar Spacc: Yes_ Noi.____
Method: Pumped_. Pressure______ �ourcd ��._ �
Depth: From � � � F�'
Materials Used: No. Bags Portland Cement.,._.—.-- Weight of 1 bag______lbs.
Yf mixture (sand, gravel; cuttimgs) -�auo� to .
ID Y'latcs: Ycs '� No `
d Y a ��ah Y�s �✓ _ No _ _.,
I HEREBY CERTIFY THAT THE ABOVB TNFO �CE WITH REGULAI'IONS SET
'THIS V�/ELL WAS CONSTRUCTED 1N ACCOR
FORTH BY THE pERSON COUNTY HEALTH DEPARTMEN'i'.
�., � �
..w1M •
� _Zq
Signarirc of Contract • Datc
�►t�olicatlon 0� �� o� �� - - . ' - . . �' Tax Alloo � A '�` 1
AmbtqttPald: j� :��� -- - - - - ..". -
�.:3�l.� � . � I��asl #: ! � _..
C�'� . • _ '
Person Ct�untv Neailh Dea�rtmertt
Emrironmentai H�itl� Sedion
- �� = � • �' � _-=-►� "-_
1��__ lu�� ►.-.--� 1 • i I _ '_i�_ 1 � -� - 'CL�1L:.i: ��l ' �C__Il _ _ ! i�_�� "i_�l _��. �.'C I■ � LL �
L:_" �� Ii �, IiL �. ' �ti�Jt�..l��l ;�'� � 1 • ; r • • l� M• �ll:t '1 � a ' — = -L�t �l -� - �
1) F�iflit�'114uNbdtiY ( �; �r-t�•� Sn.�,-n-i
yOR10 PhOflC �_�,� F'� N C— c c� c.� n!'r
BW�fll04 �taia: ��tf9 g 1' o c� I-4c� v s�.J G, •
� N�tps and addlen of c�urant O�rnar: ��` �-i�► a.rd ��„ e�Q_fit) r�e� •�
�U a� {�I � CJ1C1, � 1 �-/�l U P t/i.� �
�� la-ot�c� � !�1 C. 2 7 �'-T3
3) PmQ�ty �on: Lot atax Tarmhipc - .
Dir+e�ions fio ihe p�hl A�9 toed nemee and numbas�
4) Pr�d li� and Struc�r�s Da�crlptlan: � ea�l�t of ths iblbwi'tA �
� o) �d 4 �g O
b) Stldc BWit q AAodular 4�is Wide 4 Daubie iMde �
c) IY�unber of 8e�oam� 3 • • � Number of � cr peopie to he se�vec� Z
e) � Yes Q No 0'�yea, # of basement �dwex
fl� �tepo�al: Yes 4 No r� �. .
gj D6na�eions ot Pnoposed Shuc�se: Wldttr z S Dep�: Sce .
� Wa� 3uppiy 7j�: Prlv�te 8'(new � ar eod�g c�; Pub�c 0. C�nm�ni�► 0. S�n9 a
• � Are arry weBs on a�p p�periy� Yes ❑ No � Ifyes. locahon
� P�Ss Indtca�a o.�i�ed � Tj�pes IsYaf�n• can be �a�dasd fn oreiar of Yaar p�encs)
Can�r� �Alo�d Com�ntlonoi _AIEe�rmtivs �Jnnova�w
_.._..�D� %P�I)� • .. .
' CLEARLY STAI� Al.�. CORNEi�S AND 1JNE9 OF THE PRDP�Y.
9TAKE THE t'�RNEiiS OF ALL PROP09m 3TRUC'TllRE3.
PtEASE ATTACH �URYEY PlAT OR STfE PUW TO TH18 APPUCATION
( hereby maice � to the Petson- County He�fh. Depertment tor a s�e evaius�on ibr tt� on-a�e aewa9e c�osal aya�m �Or
ihe abava-dascri6ed prop�ty. �i agree tt�t the � af this app�r�atlon ate true and rept�esetrt the ma�rtuan � b ba
pisced an 1he pmpeKy. 1 un�nd iftha s�o is a�eted atthe intended u� c�ange0.lhs partnit shsil bec�ne i�n�id. l unde�itd
thak as a�itc�nt, 1 am r+�Ot�aibie i�ar ida�iying and merkin9 P�Y �. comers and matdng tho ai� aa�ie �Or.the
HeaNh Da of the Peraon Co�ady Heaith D ent bo. canduct fheir a+reiusiions. I emdastitnd that I am r�sspc�t�ie far notiiyin8 the
pn° � a�► vwe�nds as desiqnated bY the ArmY Catps of 6�ine�a. . .
a / • . _ . ii �i8 00 . .
'` . � a' Legat Rep�er�th+e . Ds� - .
:
�
' PERSON COUNTY ENVIRONMENTAL HEALTH
11
Tax Map il: Z Partel #
Zoning
Applica
Locada
Tn�unel.in
Subdtvision: SecUon: LoL•
Improvement Permit
A buildinq permit cannot be issued with only an Imarovement Permit
New Repair Addition l.�^Type of Structure �
# of Occupants a #�of Bedrooms -� Other
Basement? NI�A Basement��bctures? N A-
Water Supply �, y�,�
Projeded Daily Flow: �� g.p.d. Pertnit Valid For. Q-Ft'e Years ❑ No Expiration
ProposedWastewaterSystemType: -["Upe_7L— ('�n ril�J-,��_1
Pump Required� Yes �1V'o
Proposed Repair :"��m p-(),!`�a-cE� O..y,nr��- �(�D��; Y�
Permit Conditions: f �
7� �rn P --I-C�l1 � �{� i f��' -i� ; � ��.( � � /�q �1 /S�P--�'3'l, �
Owner or Legal
Authorized State Agent:
Date:
Date:_ � � "z�-J' �
The issuance of this permit by`the Heafth Department in no way gua�antees the issuance of other permits. The permit
holder is responsibie for chedcing with appropriate goveming bodies in meeting their requirements. This site is
subject to revocation if the site plan, plat, or the intended use cfianges. The Improvement Pertnit shall not be
affected by a change in ownership of the site. This pertnit is subject to compiiance with the provisions of the
Laws and Rutes for Sewage Treatrnent and Disposai Systems of the North Carolina Administrative Code.
Authorization To Construct Wastewater System (Required for Building Permit)
Type of Wastewater System� V Gt2� Wastewater Flow: ��-�g.p.d.
Facility Type:�� �, �/� � New 0 Repair DExpansion ��
Basement? 0 Yes �.D{e— Basement F'uctures? 0 Yes m-P��
Wastewater Svstem Requirements
Septic Tank Size:��-� ' �o s
Pump Tank Size: N� gallons
Total Trench Length: � feet Maximum Trench Depth: l'� inches Aggregate Depth:�� in.
Maximum Soil Cover. � inches Trench Separation: 1 Feet on Center
Other.
Permit Expiration
Authorized State
The type of syst
the specifications of this permit
--, �- -�------- -•• the application. I accept
OwnerlLegal Representative Signature: Date:
�
PCHD, rev. 11/18/99
f
Application #:
^
Tax Map #: A 2Q
Parcel #: D
• Person County Health Department
Environmental Health Section
SITE SKETCH
SubdivisioNSectioNLot#
���� �
Date
Svstem components represent approximmte contours vnly. The contractot must flag the system
Scate: l "_ /�!
PCHD, rev. 7Q112J99
Person County Health Departrnent
� G� Environmental Health Section q�
Tax Map #: �o� 1 Parcel #: / �
Zoning: Township: �DuSn y Fo rX
Subdivision: Section: Lot:
Applicant: ��� � W
Location: �� 1 yflUl19� Ch�iP�� (�i�u�L� �oad
�
Operation Permit
System Type (In Accordance With Table Va): �
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLlNA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL-_ICONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIz�ITION. n _
la-l1- o�
Date
Tax Map #: Parcel #•
PCHD, rev. 10/12/99