A29 224. � o�
Aopliratlon Date: d'�`v `"� � � � • ,�� . Tax Mao �-
Amourrt Paid- �j ��'�
Rec�i t � . /1 . Parc�l �:
d'
��� �\�_ � I�I�IE�.� �1�
� � - - �c � �CT�i�-Y
��.�.�-�--.- ---- ���.�.�. �o�.a.�.
Perm3 - $150.00
APPUCA710N FOR 3�iViC�
$750.fl0lSZ00.00 �
- �225.OD
� ��
IF THE INFORMAT7aN IN THE APPl.1CAT10N FOR AN IMPROVE�AEiVT P�RMR 1S INCORRE�T FALSiFiE�
CNANGE�, OR THE S1'fE' IS ALTERE�. THEiV THE IMPROVEiNENT PEiiMIT AND AUTHORIZATiON TO
COPISTRUCT SHALL BECOAAE INVAUD. -
1) Pernui requested b:(Ownerlag prospective own �.�1 �-tY i GS� � M eS• I�:a�� ���' V"�
Hame Phone: ���-S'1 �1.� lno 611 �a-v� D�vis �2d.
Business Pf�one: �q � G a-S'7 1 s� -1 t"i � �� �� y�/�,
►�.►` c.�c.. ICta.�-Y-�
2) Na�te aztd .address of current owner: � o r n�� n� 0.V �, � .-
~ �I, mr'D�d 2:`l 5 7 `l� �
3) Property Descriptlam Lot size: _� Trnrorufiip: Sut�division: Lot #
Directions ta the property (Induding road names and numbers):
4) ptoposed Use and Structure DescriQtion: answer ct� af the foilowing questions: C�(� S`7 r 1
� a) Proposed�� Existing , Type of Struct�.u�e: �r i C.YL 1-��4� Width: Depth: -
b) Number of �edrooms: � Number of �pants or people to be served: �_ ��
c) Basemerrt Yes �/ . No _ Wll there be lumbing in the basement?
d) �arbage Dispasal: Yes . No _ �Ct_,t� {y�. � ��5� . .
5) WaEer Su�ply Type: Private ✓(new � a� existing_), Public_, Communi�y . S�ring _.
Are any wells on adjaining propeKy? Yes ✓No _ ff ye,s, piease indicafie approximate Iacatlori on the
'siie plan.
6) D�s your property cantain previcusiy identified jurisdlctionai w�lands? Yes_ IVo � �
PLEASE NOTE THE FOLLOWING•
➢ A PLAT OF THE PROPEi�TY OR SiTE PLAN NIUST BE SUBMI7TE� WITH THIS APQLICATION.
➢ PROP�i�TY L1NES AND CORr1EitS MUST BE CLEARLY MARl�D. • �
9 THE PROPOSF� LOCATION OF ALL STRUCTURE� MUST BE STAi�� OR F�IGGED.
➢ THE S1TE MUST BE READILY ACt�SS16LE FaR AN EVAL11AT10N HY THE HE�11.JH DE3�ART61E�11'
S'i'AF�. �
1 hereby maice applicatian to the Person Caur�ty� Heaith Departrnent fnr a siie evaivation fo� the on-siie sewage disposai
system for the above-described proQerty. I agree that the cantents of this appiicatian are true and re�resent the maximum
faaiiiies tc be pia�d o� the property. I unde�stand if the siie is aitered or the ir�tended us� cf�anges, tfie pelmii sha1�
became it�v�i�d. _ � /�1 n �
owner or Legai
- �� 5 �
D
Ptl;D. tev. 061a102
`01���,�� �1: i"��iJ ��
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7E��-�� �^�^ ���.3i IE--���.11.�It�.
Applicani
Location:
c� ', —� C. A►'w.�u t a F 5cc,� c,F
Pe�mit �alad fo
Type of Facilifi�: ' l,� �on-: ��; � New �/ t�ddition �ater �npply � 7�,�c�
# of Occupants R M�.x. # of oms /�'. Pmjected Daily Flow �_ g.p.d. �
Proposed Wastewater S��t�m: Cu�v�tiv�.�i � . Type: �a
Proposed Repair: Ci rw�r,�r�o4 � w�a.0 ha.u.2 ��'o ►a.r� c,n�,;� susLc,,�. � T:YPe: 1►_ a
. � . . .
w
Ye11N �JT��rI � ' �!1"C'l-�� -,
S'LllfJ f� I'V I�wi U ll
F i�i ���5•c' S� c ti o t��%L.a t�
�n►p���effie� �'ea�$
.
r ✓ �'+ive Y�ars. rtq �`sgirat�n �.
� r.l�ll • 1 • t � 1 ' � • • �7 �w I. � `+. � . ��• � ��
, / i I I i/ /
Owner or Legal Represe
Atrthorized State Agent:
m
Date' ���� � �
Date: a - /(o -0.S
Tho issuance nf this peYmit by the Health Dep�rimc�nt� does not gua�rantea the issn�nca of other permita It 3s the respons��iiy of the
$PP��P�P�Y owner #o in sure that all Person County 1'7a�ning and� Zoning and Buslding Inspectiona requirements are met '�his
Lnprovement Pennit is subject #o revocation if the �ite Plau, plat ar the intendeal use changes. q'Le Tmprovesneaai �ertaiit is noi �ffected
by a'ehange in ow�oerslup of the Property`. �his permit was issued in complianc� with tite provisions of t6�e 1Vasth Carolina `Laws and
��or Serua�e ?Yeahnteni and Disnosal Svstems' (15A NCAC.IBA .1900). Ne.rther Person �o�tp nor the Environmental lkdealth
Specialist warrants t6at the septic tank �y'stsm wili contLtue to func3ion satiafactoritx nn the future or that the tiw�ter suPP�Y will semau►
potable. - � . .
��l.ii�oB'IZat,lOII t� Cm1��[l�'������$e�'� S�SteLii ��eqnired for ]Btuldimmg �'esmit) .
* See site ptan rmd additlonal a#achments (� � �
r��sea w�va� sy�: (��,y�,►-. �. � Type ��_ Wastewater Flow �.p.d.
New �l R.�pair Eapansion . Sa.7 LTAIt: _ a�5 g-P.d.l $ Z
Type of Eacility:. �,� � �..�u �:_.,..�_ � �Basement �a �Yes No
� i�as#�w�ter Sy�te� Reqnirements . .
Size: Septic �a�: ►2sc� gal , Pu�mp �ant�: � gal' . Grease Trap: — gal
fie1d: Total Area: ► � tis sq $ Tot� Length 5 8 5 fi 1Vlas.a�u�'I`�e.n� IDeptla i- a o a�
eh W�th 3 i# ��ean Sonl Cover: �� i n_ in Minimum Trench �epazation: _Q____ ft
(ba#iva: x Distnb�tion Boz Serial Distnbution .Pressure Manifold
Aa�#�nor�ed State �gent:
Permit F.x�
The type af system permitted is
the peimit.
��►e����� ���� ��
Date: a�/C�-t�
Date:
Conventional Innovative Alternative. I accept th� specifications af
D�: �� � `�' 0�
PCHD7/3012002
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S�'�'.�. S��E.'T�: �
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Name �� d 1 Car�.. ��,;,, � Tag #� Parcel #
� � 1. -�-, �- � Section/Lot# .
/ / - __ _ o�^ I ( n —t�s
� , Aut�o � Sta t . Date .
� // / System canrponents re�►r�se� a�rvxinrate�con�dours on y 3ise casstr��»r must, flag the systerss j�rior to
� .� beginning the i���tallation to insure ihatpr�pergmde is mcrantained
_..'w__,^°^o.
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�� � STEPHEN L. DUNEVANT h ^ *
D.B. 311, P. 199 � a �
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NF S84°37'OS°E
IF 507.81 TOTAL . 7. 3 7 A ��, si '
tu I F �5
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/ 't
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ryNA /�--- � �
z PROPOSED 50.� .�ry�"'`t'�'
, - - = - - — _ _ R�W ACCESS EASEMENT �""
— __�___ s�
NS N85'40' OS"W - - -- - - �� _ _ ,�
-- __ __ 718.01 Ng �
,
. _ — — — � � — � .� � � v� � , .
---- --- __ ��
--._� :`
� _,
� PATRICK LEE GODWIN, JR. �
/ KAREN HOBGOOD GODWIN `�
D.6.512, P. 91 � NS
�
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SANDRA BRADSHER DUNEVANT '
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---------'–___�������.�ocacGfCYY����ECCi'�CCPrrnrvnu.,an�...�����--------------------
PATRICK LEE GODWIN, JR.
KAREN HOBGOOD GOOWIN
D.8.512, P. 91
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WELL 1PERNIIT � �
PI.,EA�SE SEE ATTACH�D PLAN FOR VYE]LY., SI'�'E ��ICDiJT
Tax Map �c �� Parcel # � �' Township:
Applicant: �c.�;��. a )��. C��u�„
Subdivision: Lot # �
Location:_C.1� cS � Gi�s 1va�4. �ws TZc. � �or� c�o �� �.5'04 1
�r��.irn� `-� �u+be. is o., � : ,.r�- ►- loo, c �:� � �v Ilow c1,bc iv
�o a� �.`l1 -� �s,su- (L�
'Y'ype of Water Supply: '� Individual _ Community Public
�teqnirements:
Site Approved By: _ (�_S �- c� -�S
Grouting Approved By: � '7 -1�.cs3'
Well Log: ✓ CS �(� - r� Js
Pump Tag: ,� ` „ s�,.,.� -}�
Well Tag: v CS i��.-DS
Air Vent:,� CS 1 I- 1�-as �
Hose Bib: .� � � � -� � �s �
Casing Height: ,,/ � � � - t �=� s
Concrete Slab: � Cs � �- i��x-
Well Driller: �er�s.\ 's �J�� �:\�'�
Well Approved by: �
****Se� Attached Site 5ketch****
Liner:
�Installed by:
Depth set: _
Grouted:
Date:
Water Sample:
Date:, 1 �-f�-�S
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 buiiding foundation. �
Other conditions: 9a I 1�x,� s�'�c ska�. �
PCHD rev 01/27/04
08/02/20�5 09:33 8043740001
J�7a J't � ' � .
�� L• • �: ' �. :. ., • ,:. • o1J ��
T�'F M •
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��--'rSY�.vaa�a¢3t'��caa�7�A.��o.� ��.aa��Q.�a
HENSLEV WEL
PAGE 01
Drililei Ib � � �
Couta��Zit►y N:��i�t��� r . ,-_ . !l��i
� ,
D-,-�t�e Dri�llcc� ,
, Groat Log
Owner: I''i �- q.�' '�'ax Map� Parcel #�
L�cstipri: �-' � r
Subdivision: Lot #
Weli ConstrtrMfon
Dista.ncc From nearest Property Line (Minir.n�m 10 feet) 7D '
Distance from Septic System {Minimum 60 feet) // D'
Total Dcpth: �� 0$ Yield: ��� GPM Static Water Level: �� ft
Wattr $earing Zoz�es: ,Dcpth J��7 ft_ f�,t2_ ft ft� fi
Casing: ,
Depth: From %t to �/ ft. Diametcr: �c► in �
Type: Gaivanized Sfieel _... ✓
Weight: _ _ Thielrness: �r�,� Hcight above Gr��md: .,,,��, in
Dtiv'e Shoe: _� Yes � No A�uy problems encountered while satti�p� casing? _Yes �No
IP `�es" give reason• '
Grout� �.,Q�J-� 4�/1 Li�. �3 d b'
l�eat: _� Sand/Cement Conczete GravcUCement
�. Anbular Space Width v� inches Water in Annular Space ✓ Yes No
Method of Graut: Purnped �� Pressure Poured Depth _� to �,_w F�
Materials Used:
No. Bags Partiand eement 'Weight o� 1 Bag �`� Pounds
If mixttu�e (sand, gravei, cutti�ngs) - Ratio to
ID plates: ,�Ycs _ No d x 4 slab Yes ,� No
Liner: �/� '
,Deptb.; Date instailed: Grout:
Drflling Log
�'rom I To
I la�reby ctxtify that the above inforrnarion is
by thc Pcrsoa County �Iealth De�,�tmen�_
Signature at Contractor
a�d
Installcd by:
LocAt�o� Drawin�
, -I " `
��`, ���
���+ I10� �
^ - - - - • - Q
this well was conshucted ia accordance witta regulations set farth
ID# � r Date 7� a�9�0.�
Pump Installment
Pump Jz�stallation Contzactor: M�2 ��^ �5 l,� ',�1 �� ir� State Re� stration Number: _��% 9 --
�.,p ���, '� d � t�c Watet Level: , j�
Pump �vlaks & Modcl: r� �ip Sizc and Rstit�g: ���--- %p �L,,,� $Pm
I hereby ctrtify That this pump was installcd and the well hasd cannpl�ted according to the Ptrsozr County Well Rulee in effoct
on this date �nd that a cagy of this record hes been providcd to thc wcll owner.
� ���1,� Date: Y� 5 PC�-ID rev 01/2�/04
Yum.p �nstaller SiQnature.� �
1
`���, �� ���� ��
�-. v � �/ �� � V 1i 1i
��nv�a�-���.�rn��.��.�. ����n.�.��n
T�x M�p � � P�rcel ##
Su�bciivision
Phas�e Sect+ioniLot #
# of Bed�rooms ,
.
Applicant:
Location: �
- perat��n Perm it
System Type (In Accordance With Tabie Va): �
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLlNA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL COMDITIOiVS OF ' THE IMPROVEMENT PERMIT AND COfVSTRUCTION
AUTI-lORIZAT10D1.. �� � �
Installed By:
,'�`' � �`
_ �-�- Lo' �
�
0
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� 0
- �� E)
, 4'5 7'Z 0 8�3 C
2 s
Z �'�'S 7�Z 8,a 83
��.�2 �,s .�,Z $-0 83
l�� 7 dS
Date
Date: l�/ 7�oS
L1 14D
LZ-I�o
�3-140
�4—�ND
L5'►�D
�,
�7�0..
PCHD, rev. 07/29/04
�
�E�TiG �'A�lK 9R9S€���'�1�.h� CV�E��(L1S�.4�IPe 01- IV�
Tax Map # Zq Parce! # 2� Sys�em Type (Table Va) �
Owner/Applicant �,-ir,� a �rt�n (�1K,%+��n Subdivision
Address/Location Sec/Phase Lot # �_
State iD/date ��(�- /�5/Z-8�OS
Canacitv PfS- /2sn aai.
Tee and Filter
Baffle
Sealant
Riser (if appiicable)
Tank Outlet Seal
Permanent Marker
Pump Tank
roof /Sealant
Riser
0
Pump
. Checic Vaive/Gate Vaive
� Anti-si on o e
Floats/Switches
Alarrn visable and audible
Electrical Comoonents
Rate (gpm)
Approved Pump Model
Blocic Under Pump
Pump Removal Rope/C
n
Serial Disiribution U-baX
ressure an o
Low Pressure Pipe
Appr. Pipe Material and Grade
�uate NI'tP'iTiC1t1017 LIII
t� 7-a rencf� Width �
� Trench De th -
T,rench Len th
Trenct� Grade �
Tcench S acin
� Rock De�th and Qua
ft.
in.
ft.
Dams/Stepdowns etc.
Pressure Laterals
Hole Spacing
o e ize
Pipe. Sleeve
Tum-ups/Protectors
Required� Setbacks
From Wells �
From Proaertv lines
Surface Waters
Public Water Suppl
Vertical Cuts (>2 ft.
Water Lines-
Vehicle Traffic
Easements/Right.of V�
Other
Easements Recorded
e e pera or ai
Tri-Partate AQreemen
Commenis
�-
pcnd rev. 3/13101