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IF THE INFOR�AATZQN IN TNE APPLf�AT10N FOR AN IMPROYEMENT PERMtT IS IN RRECT FALSiFIED,
CNANGED. OR THE SR� !S ALT� D THEN 11iE IMPROVEM�TIT PERM�T AND Alfi�lOR1ZAl10N TQ
CONSTRUCT sHA�L BEcoME INVALro.
1) Pormtt requeatod by: (Ovme�lagerrtlprvspectivs owno�: �'�SS �
Home Pha�ne: `�3y-� L�= b00� %�ddress= Z
Busfness Phone:
2) Name arid �addresa of currerrt ownar: ��� nnw o�
3) Property Doac�iptlon: Lot size: �`(�-Township:
�irections to the prvperty (tnduding road names and numt�s ): _
R�,r�►�?�1. — �k�Cc'k►,r S^�or�
�
Lot #
4) F�ropossd Usa and Struduro D�scrlptlon: answer each of the foN�Q''�ing questiats: o�
a) proposed � ExEsting � Type af Strudure: ib�bh"�,t Ht�YI� Width: 0�0 Depth.�
b) Number af 6ecinooms: Number of occupants or peop�e to be served_ �_
c) Basemec� Yes_, No�, VVi� th�e be plumbing � the basement? —
d) 6arbage Disposal: Yes � No✓
� Water SuPply TYpe: Private ✓(new ✓ o� exisUng� Pubiic`, Communihr� Spring _
Are any weHs ori ad'pining p�ope�t}i� Yes�No _ tf yes, please i�icate apprrndmate locatan on the
sfte plan.
6� poea yaur property co�in p�vviousty IdecrtiRod lurisdlctlo� wettands? Yea____ No=/
P 8E NOTE
➢ A PLAT OF THE PROPERTY OR S(TE PLAN MU9T BE SUBMITTED WITH THIS APPLICATfON.
➢ PROPERTY UNES ANO CORNERS MU3T 8E CLEARLY MI►Rf�U. ,
➢'T7iE PROPOSED LOCATION OF AL1- STRUCn1RES MUST BE STAi�O OR FLAGGED.
➢ TNE SRE MUST BE READtLY ACCESSIBLE FOR AN EVALUATtON BY THE k{EALT}i DEPARTNlEP1T
STAFF.
I hefeby make applicatio� to the Person County Heatth Depsrtrne� for a site evalu�lon for the orrsite sewa9e disPos�l
system for the above-described property. I�rea that the caniant� vF this application are hue and represent t�e maximum
facilities to be ptaced o� the prope�ty. I�derstand if the site is aitered or the iMended use dianges, the permh shall
become irnatid.
o � c� /— 6 �
� Owner" or Lega Repn�entative ��e .
ac�+o. �. oemroz
��� S.f ���$.���
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�" �n.�n��n�n�ac��n�.�n.� �'""�a�a�.���n.
Tax M�� • P�rcel u
Subdivi�s�ion
Fh�s�e Sect�ion Lot #
Applicant: �2'ge �•11
Location: �I � o� 1 < i � � t- '
c�+c� ��: L.x�
Improvement Permit
Permit Valid for ✓ Five Years No Ezpiration
Type of Facility: ' `I New ✓Addition _ Water Supply vo.k
# of Occupants (v # of Be ooms 3 Projected Daily Flow 3�� g.p.d.
Proposed Wastewater System: (�1,,,����.tY,aQ Type: `�'a
Proposed Repair: �kZ �ZS'/ f'¢c�cL�+�.� Type: �o
Permit Conditions:
Owner or Legal Represe
Authorized State Agent:
�--
Date: % - c� 7—i� �
Date: co - acc-�
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 Inspecrions 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 %r Sewa�e 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 (�J. �
Proposed Wastewater System: l on.n..�•-�Q Type,� cz Wastewater Flow3� g.p.d.
New ✓� Repair Expansion Soil LTAR: . 2� 5 g.p.d./ ft 2
Type of Facility: ��1� �'�,1.,, Basement _ Yes x No
Wastewater System Requirements
Tank Size: Septic Tank: Lc�t7�'� gal Pump Tank: �-- gal Grease Trap: gal
Drainfield: Total Area: �_ sq ft Total Length ,y� ft Maximum Trench Depth / g 22 in
Trench Width �_ ft Minimum Soil Cover: �� in Minimum Trench Separation: q ft
Distribution: X Distribution Bog Serial Distribution Pressure Manifold
Specifications: +�-� { kx.� S�; k, Slc�k�l.. '�Y+�c.i�. ��- Q ��,�t-�� �1.9-a`n�c,.�`^ c�.� saJ�c�a �—
Authorized State Agent: ' 'IGS Date: cn - 2�-oCn
Permit Expiration Date: Cc - 01 -\ 1
The type of system permitted is � Conventi nal Accepted Alternative. I accept the specifications of the
permit. �, a� ��
Owner/Legal Representative: %� �- Date:
PCHD rev. 11/10/OS
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�I'I'E SY�TC�-I
Tag Map #�r .2g Parcel # 23i
Section/Lot# I
� Co-acQ-o� �
Date
System cbmponents represent approximate�contours only: The cvntracrtor must, fiag the system prior to
beginning the installation to insure thut, pmpergrade u maintained
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Tax Map �1�_ Parcel # Z3L_ T'ovvnship:
Applicant• �es,s.e. �;��
subdtvts�°n Lot # 1 .
Location: S� a-. f-IrtSicn S J�''c' � o.. O/:i�.- �„ iZ� -� 1� �,
d�+ �' �'W� 'J�.i� IS�' Zar+ck. �'lcxsaa � .
��e O� �a�d' ►�11��D�Dly:
��UIH'�ffi@Iat.9:
✓ IIId1Yl�.i1'i� _ COID1T11IIIltj/ P11�I1C
Site Approved By: �-11 ��� � ob
Grauting APProved By:�-4 � I� � 1 d��
Well Log. ,/ • �
Pump Tag: •
Well Tag:
Air Vent: ✓ � � ��
Hoae Bi�b: ✓ �
Casing Heigh� ✓ '
�Cancrete S1ab: / � �
Well Driller• ��r�.�
Well Approvec� by: _� �� /-�
�-�*9ee..��ched Sate 31�tch*=*�
Liner.
'Insta.11ed by:
Depth set: _
Grouted•
Date:
Water Sample;
Wells must be 10 feet from property linea. �
��1Vells muet be 100 feet from septic systems.
Wells must be at least 25 feet from auy buiiding foundation.
Date:_ 7 �( �4�„
s �- .�� ..� . . :, - ►i • —.
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Jul 14 06 12:57p Keith L. Barnette 336-598-9275 p.2
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Gruut Log �
p��: �� e( Sah Tax IGIap��°1Z 7 Parcel #
LliCi8ti0II: i J11 �� 5l'� Oh � ib'!� �6 K�• �+OZ � N
Subdivision: Lot #
� WeII Constrnction
Distaace From nearest Property Line (Minimuzn 10 feet) �[v t
Dista�ce from Septic Systein (Minimum 6U feet) 100
Totai Depth: 3� ft Yteld: 3 -_ GPM • St�ic Water Level: 2� ft
Water Bearing Zones: Depth [�n ft Z5b ft ft ft
Casing: i
Depti�: From . v to $`'� ft. Diameter. 6� i�►
Type: Galvanized Steel ��
Weigh� Thic1Q►ess: J 18$. �Ieight above Groimd: �� Z in .
Drive Shce• -TYe_s No Any problems encountered while setting casing? Yes t/�Io
If "yes" give reason:
Grout:
• N� � SandlCement ✓ Conctete GrayeUCement , .
.-. Aniiular Space Width � inches Watsr in Annular Space Yes No
Method of Grou� Pumped Pressure Poured � Depth D to Zv Ft
Materiats Used: � .
No. Bags Portland cement ' Weight of 1 Bag Pounds
If mixture (sand, gravel, cuttings} — Ratio to
� �1�; �/y� `No 4 x 4 slab �Yes _.No .
Liner: -• �., .
�p�: Date �lled: Grout: Instailed by: .
DriIIing Log � Locatiuon Drawing
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I hereby certify that tlie above inf tian is correct and that this well was constructed 'm accordance with regulations set forth
by tiu Person Couniy Health � �
Signature of Contractor � ID # � D�tte . � `'�`�' � 6 ,
� pnmp Instaliment
Pump Inst�llation Contracbor. ���n.c. �!° '��� fll�L�^°l State RegistrationNumber: _ Z��
pump� Depth: ft Statia Water Level: ZS ft
pump Maloe & Model• c.k.c �' Pump Size and Rating: ��2 11P .,�c�,_ gPm
I hereby cerrify that ttris purng was ' talled and the well head campieted accord'mg to the Person County Well Rules in effeet
on this date and that a copy of this curd h been provided to the well owner. .
Pnmp Installer Sign�ture � Date: �" ��l'v �' PCHL� rev 01/27/04
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Tax M�p � �� P�rc I •
Subciivision
Ph�se Sectior� Lot #
# of Bed!rooms
Applicant: .�5� �h\� � �
Locaiion: ��� -� � nn 4�� S-�Z��re Rd y-�) on ol'ive�r (�-,n Rrl -'r lbf on � iv5�- C��e✓
. �Dr i c k 1r,-��e •
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System Type (In Accordance With Tabie Va): � o--
THIS SYSTEM HAS BEEA1 (NSTALLED IN COIiltpLiANCE WITH APPLICABLE . NORTH
CAROLINA GENERAL STATUTES, RUtES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITiOFIS OF � THE IMPROVEMENT PERMIT AND CONSTRUCTI�N
AUTHORIZA'TIOM. • �
. � ��� /� .
Authorized State Agent
I nstalled By; �rn m�, L9.�,���5
. r.. �c�;�n�
�/��-/� .
Date
Date: � "7 �i�I ��
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P� S I c�
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PCHD, rev. 07/29/04
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��P�IC T�K iNSPE��'i�R! �C�iE+��15? (�'yP� li - I�
Tax Map #�. Rarce! # a?, I ' Sys�em Type (Table Va) ��
Owner/Applicant ���� !�-F;\l � Subdivision
Address/Location SeclPhase Lot # I
� � Septic ianE� nit � at� �tr� �cat on in� nA�aa aie �
State�ID/date -�� -� ,, H-��� 1 Trench �dth� ft. � -�I� I
Ca aci �,�,y;� . al. �� � Trench De th l in. ✓
Tee and Filter - � � Trench Len h ft.
� Baffle ,� � Trench Grade � � �
� Sealant ✓ Trench S acin ✓
�_.� � Riser ifi a licable ✓� � Rock Qe th and Quali ✓
• - Tank Outfet Seal - DamslSte downs etc. � �
Permanent Marker Pressure Laterals � �
. Pump ,Tank • � Hole S acing �
tate a e o e �ze
�-- �' Ca aci al. Pi e.Sleeve
� Wate roof /Sealant Tum- s/Proteciors � �
Riser Required� Setbacks
Water� Ti ht � From� Wells '✓ � I�1
Purr�p From Property lines .
Check ValvelGate Valve Structures/Basements
�� nti-si on o e i c es rama e a s ,�
� Fioats/Switches � � � Surface Waters ✓
�41arm visable and audible Public 111later Su lies ✓ �
Electrical Com onents � Vertical Cuts >2 ft. ���
� Rate m <:. Water Lines � � �
A roved Pum Mode! VeMicle�Traffic � f
Block Under Pum � Ad'ace�t S tems � r -
� Pum Removal Ro e�Chain � ,�Easements/Ri ht of Wa
: �D'istribution:System Other �
' n�- � N� I� 1ab Easements Recorded
� ressure ani o e e era or on rac
Low Pressure Pi e � . Tri-Partate A reement
A r. Pi e Materiai and Grad� � �
..-�- -:- . .
pcf�d rev. 3/13/01