A29 230Anpiication Date: 3 � 7"� `
Amou t� Paid: . �
Recei t :
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Tax Map #:
Parcel #•
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APPUCATION FOR SERVICES .
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFfED,
CHANGED OR THE SITE IS ALTERED. THEN THE IMPROVEMEI�T. PERMIT AND AUTHORIZATION TO .
CONSTRUCT SHALL BECOME INVALID. -
1) Permit requested by: (Owner/agent/prospective owner): r J S �c.�iJc p u*���- 1''�4 J~� � ���� r
Home Phone: 'Z (� �-�?� � Address;,� � r« "t.,l
Business Phone:S��- i�'G-Ra � 5 � �j ►. �� �- � ^'c L> � �,�
2) Name and address of current owner. �J'�',fi-c.� J� �q 1 J h�+ �� �! A�s � �2 �.�-t �s � r' �
' � C—� St c� �ze.�� �
3) Property Descriptlon: Lot size: ( ,nc Township: ?���� Su
Directions to the prope�j (Includ�ng road nam'eIs and numbers): ���
�.1.- � rf w ��tr �C.� � �' J Z�3 h I l L 1
�
�ot��4�-
vr� R�
��tti��✓ 1 .��
4) Proposed Use and Structure Description: answer each of the following questions:
a) Propose�--�cisting . Type of Structure:� ti+���� ��� �dth:� Depth: 3�
b) Number Of Bedrooms: �.�, Number of occupants or people to be served: 3
� C) Basemen� Yes_,�Ne C� �il there be plumbing in the basement?
d) sarbage Disposal: Yes � No�
5) Water Supply Type: Private �new _ or existing�, Public_, Commun'ity_, Spring _
Are any welis on a joining propertyT Yes o_ ff yes, please indicate appro�umate locatiori on the
'site plan. d'`���c�"'✓
6) Does your property contaln previously identifled jurisdictional wetlands? Yes_ i�
PLEASE NOTE THE FOLLOWING:
➢ A PLAT� OF THE PROPERTY OR, SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY L�1NES AND CORNERS MUST BE CLEARLY MARKED. �,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAlCED OR F�AGGED.
➢ THE SITE MUS�' BE RF�►DILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF. � �
I hereby make appUcation.to #he. Person County Health Department for a site evaluation for the on-site sewage disposal
system for the above-described property. I agree that the contents of this application a�e true and represent the maximum
facilities to be placed on e pro� rty. I understand if the site is altered or the intended use changes, the permit shall
become invalich � � /�/
Representative
?_L-� -c 4
Date
PCHD, rev. 08127l02
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�s�nwn���nn�xac��n�.�n.� �`"'��an.���n.
Applicant:
:Y, r�-�-
Permit Valid for ✓Five Years
Type of Facility. ',ro
# of Occupants # of Be�
Proposed Wastewater System: �
Proposed Repair: �1cc.���_
Permit Conditions:
... � . . n . _
�
Improvement Permit
No Ezpiration
New X' Addition _ Water Supply ,nvc�-e,
Projected Daily Flow 3co� g.p.d.
Type: jlp,
Type: �� n , b
� �
C�.a�Qr (c7+QT ¢n��'Q SQp�,Z C�QG ?v
Owner or Legal Representative S' a e•
Authorized State Agent:
T�x M�p + ,. F�rcel #
Swbd'ivi�sion
Fh�as�e Sect�ion Lot x
a
Date: S 1 �-��
Date:s-t�
The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site 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 compliance with the provisions of the North Carolina
`Laws and Rules for SewaQe Treatment and Disposal Svstems' (15A NCAC 18A .1900). 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.
Authorization to Construct Wastewater System (Required for Building Permit)
* See site plan and additional attachments (�. �
Proposed Wastewater System: s�v�-..�-�✓ Type� Wastewater Flow�� g.p.d.
New �C � Repair_ Ex ansion Soil LTAR: ��s g.p.d./ ft 2
Type of Facility. '.,clx �..� Basement _ Yes >C. No
Wastewater System Requirements �� ^ ��� �
�..E�►'�� ���T��.� .
Tank Size: Septic Tank: � gal Pump Tank: -�-, gal Grease Trap: '— gal
�a "
Drainfield: Total Area: I �` sq ft Total Length �l �l c'� ft Maximum Trench Depth 1 R� in
Trench Width 3 ft Minimum Soil Cover: � in Minimum Trench Separation: Q ft
Distribution: X Distribution Box
Specifications: �.la��c,�h aS�2ll �-
� �,� a5� �,;� � ��,-
�
Authorized State Agent:
Permit Expirahon Date: _
Serial Distribution _
�
�1\�,� s:k
�� ���L_
Pressure Manifold
Date:S' »"a�t
The type of system permitted is � Conventio Accepted Alternative. I accept the specifications of the
permit. S�� j rl —zi 6
Owner/I.egal Representative: Date:
' PCHD rev. 11/10/OS
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Name � u-•�•. I�` r . �T� Map # F12�► � Pa�rcel # 23`�
S 'vieivn Section/Lvt#
�$'• 5- tco�oco
.Eluthori ed te Ag�nt � Date �
Syrtesn co�or�e�ts t�,�ireae�t a�iproxis�ate contours on�y. Th� co�atnact�nr must, fla� the sysi�ns p�ior to
b�aginnirzg the i�tstc�ldation to ina�es�e thatpt»pergr�,de is maintained .
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�'�.c�1E ��+E�A�A�� ��N �'�]L�'8�� �I� �.4IQ��J'�
Tax Map �_ Parcel # a� .. Township: � 1��, d�.1 r
Applic�t: _ C�a�,�,u W�zn-.
Subdivision. Lot # .
Location: �g � -� a.. �s� �-� � -� • «-, (ti�o W �. Gv�.,r„ �► �
1��. �� � _��-, c�..S2- c'�-sc.�.. • _
Type of �la�er 5u�p�y: �ndividual _ Commnnity Pui�lic
�B�UIH'eII1'be1R�:
Site Approved. By: � �� _ � �p�
Grouting ApProved By�� [� - �� �„
Well Log.
Pump Tag: � •
Weil Tag:
Air Vent: ' ��-z��
�iose Bib:
Gasing Heigh� �
Concrete S1ab: � � '
�- . �
Well Driller: �os}- �;��1 �
Well Approved b : �
�-�*9ee �t�aached Site 31��tc�a*�*�
��
Liner.
'Installed by: _
D�pth set: _
Grouted:
Date:
Water Sample:
Wells must be 10 feet from pmperty '
Wells must be 100 feet from septic syste , -
. ells must be at least 25 fee# from any buiiding foundation.
Other conditions: �� ��.� S��e. 5l�}c9�. cS� v
. wa�l
2�s�
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Date: ,�, - Z� rj (o
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,
P� rev OI/271Q�
JUN-6-2006 06:00P FROM:BEST WELL & PUMP 19199654494 T0:13365977808 P.1
B6/06(2I7B6 15:A'.7 336`J`J7/dbl3 ��N�ti�"�.SUN���4�1RJNiY�}hJ'VVf1tiU F'Al•.� pt
`..��' '"�1���� �. `�' . �.LG.+3.��/ : .� ' �...u�R1N UV � _____QS__'7 7 � �
., :� •Q� ��� `� � ' � � �� �e���
��•���o��.�*s.�ll ]��,a:�►.11�..•
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Loaation:
� ��06
...........,_
Grout Lo$
_T�MwB:�.�r r�d#.zaa
3ubdivi�ioa: �# �
��
W� Conah�ctla�
Disdmce From ne�rest Praperiy Line (Mini»�um' I O i'eet) /���
�acc h�m Septia Sy�Oem �ra 60fqet)/� r..
Torai Ikpth: �$�eld; /,_,,,�, G1pM Shtic Water �vel: ��„ ft
W a t e r B c a T i a� Z a � n e s: Degth,,,� f�.� 8�w ft �`� ft
CRefass . '
Depth: From i, O��- a� ft. Diameter: jp,�„ ia
�►p�. t�1vAn3�r13teW ,,,Y�,g„"
�� �____.._, Thtc7rn�: •� 8�, Hcight ebove Qmtmd: ,�„f 2 �a
,� -r-�-- Xos 'No Any probleias cncouot+�rect while eetbir►g c�ing? Xee ,,,� I+to
zf'j� giw res�on:
�ron�•
Nesr, �' 3andlCaYlent,_r,_, Conont� GrsvCUCemd�t,_�
AAauLr Sp�ce width „�.3 ` inahea wata tn AnauIat 5�ace �Ye� No
Method af �'irou� Pt�ped .,,�,,. �etSure ,�,.^ Poimd Depth ��_ ta Ft, ( oP �� �' a�e v►`�
M�tuW,e Qtpd•
�Ja. �a� Porttaad cemaat� W�� o� 1 Bag��,Pozmds
If m�xtura (s�aad, grav�l, t�&�) � Katio td �
,ID plates: � Yee ,,,, No d x 4�1ab � i No
Line�:
D'�P� pata Inst�lled: (}rott� �� InaWled by: .
71�J1fL_ T __
I ha�e'bY oarci�► that tha �bove itiformuion is co�ct md i�t thia wetl w�a cans�ucted in acaadanc� wifli repulatloms aet fa�fh
by the Persoa Cou�nty Healtb Depertment ,
Sign�t�pn of Cnntiiyecbnr
�D #�/�� Datd 1o"la _ Q(v�
Paulup Iait�lbnent
I'ump InetnTIaRioh Cozitr�ctar:l�aaln�u n r��.�? _.w-.� State Registxatian NUm�bq�; _�5_Ya� 9
��P ��� �D R txtic W�ter T,cvel: �� �} �•—
Pump Mekc & Modol: _ 2 e cT4�! !.� , C:.ct_.�.. p�,P Sizo end Ratin� ,�....hP. _! �- ._ �
I��Y certify th�t this pmnp wa9 inetalled attd 4�e weIl bead cempleted ecca�din� w t�e �araan Cou�qr Welt Butea in e�ff'eat
on thia date and that a aopy of this roaard has beGt► prwtded tio t'he well awnq'.
I'"4mp Inshli�ur St��fitr+e � Daf,e: �- . l%6 _. �'� rcv 41/Z71�4
S
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�,. �" y � � � �..L., �7 � �
�s��i�-ao�� ����� ����.�.��
cix lY.la ' � � c�rC"'� , . •�
Swbci6vfsian
� ha.s� Se�hioi�: ot .'
=� of Bediraoms
� • • � �� .. .� . . .i• ..
• • � /� �
` � � i. . C, • � �
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- ra�� � er i.t � . �
System Type (in Accordance Wiih Ta�ale Va): a- �
THIS SYST�fl� FdAS BEEN IMST�►Li.E� [I�! CO�IIPLIANCE Wt��i A►P.PLlCABLE NORT}-f
CAROLl� GEiVERAL STATUT�S, RULES FOR S�VAGE TR�ATIUiENT AND DISPa$AL,
AND ALL CONDITI�NS OF ' THE IMPROVEiViERIT PE�IIIIT AAlD COi�STRLIGTiON
AUTHORlZATI�iV. �
� � � � --a��ao . - ..
Authorized ta e A rtt Date �
lnstalled By: ��a �\1:Q. Date: (o - a -Ob ' �
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Tax Map #��q Parca! #�� Sys�e�n Type (iable Va) _�Q
OwnerlAppiicanf ,� Subdivision
Address/Location Sec/Pt�ase Lot # �
. Septic Tank nit�� a� a� �c�taon n� ni�a a� �.
� State�ID/datey-a�- .,�rz � Trench UVidth � 3 � ft. .� ' c,^ ..o� � �
Ca ac' ,�x, . ai. � � Trer�ct� De � th _ ay � in. .�
Tee and Filter Trencn Len y fit.
� Baff1e � Trencfi G�ade � � �
Sealartt Tr.ench S ac�n
� � Riser ifi a iicabie � � Rock De th and� Qual' ,� �
• Tank Out(e� Seat � Dams/Ste downs e#c. ��
Permanent Maricer - Pressure Lat�rals � � �
Pump i'ank � Hole Spaci�g � � �
tate ate o e �ze
.. Ca aci � ai. I� � Pi e. Sieeve �
� Wate roof /Seatant Turn-u s/Protectors � �
Riser � Requi�si S�tbac:c�
Water Ti ht �� From� Wells �� � ,.
- . Pua�p From Propeety lines �
. Chec� Valve/Gate Vaive Structures/Basernents
�� Anti-s� on o e rt es ra�na e a
FioatslSwi�ches � Surface Waters �
�larm visable and audibie Public Water Su lies � � N a �
Electrical Com oner�ts � N - Vertical Cuts '2 ft. •
� Rate m Water lines �
roved Pum ii�ode! VeF�icle�Traffic � �
B(oc� Under Pum Ad'acen# S ms
•� Pum Remova! Ro e/Cl�ain - �Easemenis/Ri i�f.of V11a
. � D"astaabu�io�. S��t�s�a _. 04her . �
� Seriai Distribution �_ _ . Easements Recarded
� ressure an o � erator orrtract �
Low Pressure Pi e .�ri-Partate A reement �
A r. Pi e it�a�e�ial and Grade � ` � -
� Valves �
Cornments . .
�c�d re��. 3/'i3J01
��k- w.L1.. �-�9^^�w-, �� �: c � to - a 1-vle
�L � j�� - (� �e -�i,�aL
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