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�-029-�'�
Ser�ices Requested.
Permit. (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing)
/Impxovements Permit (Unrecorded Lot)
Improvements Permit (Mobile Home Replace)
Improvements Permit (Addition)
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E--� ; ;
,, ` Water Sa"t
O _ . . .> ; :
Bacteria C mic
1. Permit re ueste : .
owner/prospective owner/agent:
ddress:� � s5-� • � �,�� S7`�
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ne Phone #:_gd � - 793 6��'3 /
iness Phone #: 9'!D —��`]� i�0 Z�
Name and address
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: Lot size: �•� a A e
. Tax Map#: � . .4 a °I y��i%.911-F'N
Parcel#: - �.5� __ ��'��
Townshin: � � Z
. Directions to property: State Road #& Road
lames,�tc.
� - -
Number of occupants or
to be served:
Repair/Replace existing Septic System
Permit for New Well
_ Replace Existing Well
eum
_ Lead
7. Dimensions or Proposed Structure: w
Width: /� o D s ��- ��i �
�
8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility
that this sewage disposal system is intended to serve?
9. Water su.pply type:
private�public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No �.
If so, identify location:
10. Type of structure/facility: Proposed: DExisting: L�
Type of dwelling:
House: ❑ Mobile Home: C� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: � �
Garbage Disposal? Yes ❑ No 0
Basement? Yes ❑ NoQ If so, # of basement fixtures:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Person COunty Health Depal'tment for a site evaluation for the on-site
sewage disposal system for the above described property. I agree that the contents of this application are true
and represent the maximum facilities to be placed on the property. I understand if the site is altered or the
intended use changes, the permit shall become invalid. I understand that before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of
the site by the Health Dept., this application shall become void and all fees paid forfeited.
Signe� Owner or Authorized Agent
Permit Issued ❑ Signature� Date
Permit Denied ❑
Plat Observed ❑
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9. SITE CLASSIFICAT70N(SEE BELOW) �
SOIL SERIES
S-SUITABLE PS-PROVISIONALLYSUITAIILE U•UNSUITABLE
RECOMMENDATIONS/COMMENTS:
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, s[reams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns� CtC.� C:WMIPRO�DOCSIAPPSEC.STIFINANCE.PC
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT
B 2397
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # � � 9 Parcel # � �J"
Owner/Contractor
Location/Address
Subdivision Name �;�( �-,G� v Q� Lot# �
SEWAGE SYSTEM SPECIFICATIONS
Repair � Lot Area I.� L
SFD � �- Mobile Home
Business # of Bedrooms y
Permits may be voided if site
Well and Septi�ayout by
Comments: �,t.n�
or
S.R.# � 110�
Size of Tank 1� �
Size of Pump Tank `
Nitrification Line S<3c5 `X '
Max Depth Trenches �,2 �-1 � �
C �Q-m �2!'61 � � r ���- -�
nde� use changed. � ` `n � �
.o
rv� ��— ���' � :.�c��. �c�'�r �
t'e Installed by Approved by
ell Permit Paid ❑ WELL SYSTEM SPECIFICATIONS
Site Approved
Well Head Approved,
Grouting Approved_
Comments: 1�Un
_Semi-Public Required Slab _
Replacement Air Vent
Required Well Log
Well Tag
SP�'�1�-1–
/
Date Installed by Approved by.
This report is based in part on informatio� provided the homeowner or his/her
representative in the application 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
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•Application Date.
Amount Paid: ,10 D �
RecEipt #: 17 1 �� E
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�� a-a.�5.a-oasT-�--�• o�.�m71 IF—���.IL�7�s
APPLlCAT10N FOR SEiZY1C�S
iax Mau #:
ParcEl #:
� Call
Nea � t�daM, �e.{}--
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IF THE INFORMATION IN THE APPIICATION FOR AN IMPROVEMEiVT PERMIT IS INCORRECT, Fa4LSIFiE�,
CHANGED OR THE SITE IS ALTERED THEiV THE IMPROVEMENT PERMIT AND AUTHORIZA►►TIOId TO
CONSTRUCT SHALL BECOME INVALID. -
1) Permit requested b:(Owner/agentJ�ospective owner): ���5� �'�/ ���
Home Phone: - 22- �a o Address � l,Gr �/� 7`v �/,_� l4T�,
Business Phone: �,r� �V �� o L � �r���S� �
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2) Name and address of current owner: �¢ f� �'`�,�¢ ��� Ui�'
3) Property Description: Lot size:�� Township: G.l% N��; �� Subdivision: Lot # ,
Directions to the prope (Includ►ng road names and numbers): S �,���-�%�-s
� P
G � �
4) Propased Use an�1 Structure Description: answer each of the folloyving questions: �y � a
a) Proposed .� Existing '' , Type of Structure: /i/� 00� �G f�� Width: �� d Depth:
b) Number of Bedrooms: �_ Number of occupants or people to be served:
c) Basement: Yes , No �tNill there be plumbing in the basement?
d) �arbage Disposal: Yes No �
5) Water Supply Type: Private t/ (new !/ or existing�, PublicJ Community� Spring _
Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate locatiori on the
'site plan.
6) Does your properiy cantain previously identified jurisdictional wetlands? Yes_ No �
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR S1TE PLAN MUST BE SUBMITTED WITH THIS APPL1CATiON.
➢ PROPERTY LlNES AND CORNERS MUST BE CtEARLY MARKED. �,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAI(ED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATiON BY THE HEALTH DEPARTMENT
STAFF. �
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposai
system for the above-described property. 1 agree that the contents of this application are true and represent the maximum
facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit st�all
Owner or Legal
r % D C�
Date
PCND, rev. 06127/02
i •� Te�x ���a:� / • �PC►�� �
l'� � : I � � ��) :�' , _
, C �.� C \ � � • � Subd�'ivi�sion
. , , . , , .. ,,., , ,�, - .., � 3, I I I _� I � I., Ph�:s�e Sect;i�on'Lot fi
•.. .�
� ,
��rmit Valid %r �
Type of Facility:
# of Occupants �]� I
Proposed Wastewater
Proposed Repair:
Permit Conditions:
�
# of
Owner or Legal Representa.tive
Authorized State Agent: _�
Improvement Permit "
No �zpiration ����
. New � Addition �ater Suppiy —�,''^T_
s � Projec ed Daily Flow ��v g.p.d.
� -�,'til.tq � Type: �
Type:
'� i �
��''e�e �►
t�a�o.
Date• '� �
The issuance of this permit by the Health Department in does not guarantes the issuance of other permits. It is the responsibility of the
applicantlproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requiremeats are met This
Improvemeflt Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvemeut 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
`Lrnvs and Rules for Sewage Trentment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the
Environmeutal Health Specialist warrants that the septic tank system w�11 continue to function satisfactonly in the future or'that
the water supply will remain�potable. �
Authorization to �onstract Wastewater System (Required for Building Permit)
* See site plan and additional attachments (_�.
Proposed Wastewater System: {'V1��pl� n�d� (� Type� Wastewater Flow �.p.d. .
New � Repair Expansion � Soil LTAR�__,��� g.p.dJ ft 2
Type of Facility: Basement Yes No
t a
�i7astewater System Requirements
'Tank Size: Septic 'Tank: � gai Pnmp Tank: ���% gal Grease Trap: gal
�rainfield: 'Y'otal Area: � sq ft Total Length ��� ft 11�a�mum Trench Depth l� in
Trench Width � ft 1Vlinimnm Soill Cover: ,�_ in Minimnm Trench Separation: � ft F? . C'�
Distribntion: �istribntion Bog S ial Distribntion � Pressnre Manifold
Rna��fira?innc-3GTi��Y/�,w � �L=�'LI�`VC �lT'�l�Cl�n �ti4^C�/1/� I c!�(//!/�7��
Authorized State A.g�ent:
Permit Exv:
d.—�
Date: /m " �/ —v
The type of system permitterl is � Conventional Accepte3 Alternative. I accspt the specifications of the
P�t. � ti� 1�--�_ ��
t�w�ner/�,�gal �tepresentative: � Date:
' PCffi� rev. l l/10/OS
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Tax Map: �2R Parcel #: $ Date: p`'d
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`� ft of line x 65 gal er lOQ ft 2��� �; IOU = Z�l6 gal
75 °lo z�Y�v g a 1= Zl � gal per dose �_ g a l per minute ( g pm) _]Rlow Itate
Friction H d
I.oss: .�l ft per 100 ft o�pply line x� So ft of snpply.line =10Q =�•�S ft
�p .� ft z 12 _� ft of fnction head .
Manifold Size: �� „ Forc� Main Size: Z » pyC - .
�otai i)ynamic �ead =�ft of Elevation head + Z ft of Pressure head + 7� Sft of
Fricrion �Iead = Z�o TDFi �' ��v�
]Pum Re ent's� GPM @ � /
P quirem � Z fo . ft of Head��
Drawdown:. � l S�ai per dose � 21 gal per inch =�o inch drawdown per dose
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Location: 0 7 D �ver � . —
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iilS SYSTEflIi i-�AAS BE�i�d il�tSi'.ALLEi� IN Ct�MPLlANCE WITH APQUCABLE NORTI-t '
CAROLII�d�► f EiVERAL ST�'rL1TE�, RUL.ES Ft�R S�IIA�fi TREAT�RltE�lT AND D1SPaSAL, •
AI�D ALL . CahlDl'iitiNS � OF ' THE 1Bt1PROVE�dE.i�ilT PEi�lVIIT Al�Q CONSTRllCT1oN .
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lnstalle.�i ;�?�a�1�. � Date: �j ,29-010 . .
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OwneN?,�plic�nt � Subdivision
Addi�ess!l,.D�ca#ion Se�lPnzse Lo# � �
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WELL PERNIIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map �( Parcel #
Applicant: P
Subdivision:
Location:
�C/ Township:
. �
Lot #
Type of Water Supply: � Individual _ Community Public
Requirements:
Site Approved By:
Grouting Appro ed By:
Well Log:
Pump Tag:
Well Tag: �
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab: __
Well Driller:
Well Approved by:
****See Attached Site Sketch****
,y�� l�t' �GN�
S�
Liner:
Installed by:
Depth set: _
Grouted:
Date:
Water Sample:
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 building foundation.
Other conditions:
Date: ( ��! ���
PCHD rev O1/27/04
Nov 30 06 04:36p Keith L. Barnette
336-598-9275 p.1
t . . . � OD � .�-t� �
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�__._,� � �.-��� �" , Q � . ° � � i l'� F(� �''l2 � „�%/ �f i �"`�
7E��a���.;,..,,.,, ��.d.�,.Il:: IL���I1.�t.I�... � � '�s
�' ,
Owner: �(���
Locaaon: � ve �
Sui�division:
Grout Log � �
Tax Ivfap Zy Parcel # � S
Lot #
. = WeII Constraction
Distance From nearest Property Line (Minimum 10 feet) f��
Distance from Septic System (Minimum 6,0 feet) 1 f,`c�
Total Depth: �.�_ ft Yield: � GPM • Static Water Level:
Water Be�aring Zones: Depth `?v ft ft ft ft
ft
�; j !�
P� ���
��
Casing: �
Depth: From .''C� to �Z- -f� Diameter: �7 l!� in
Type: Galvanized Steel �/"
Weight: Ttuckness: � Height above Crround: j.� in ,
Drive Shoe: ✓ Yes No Any problems encountered while setting casing3 _Xes c�No
If "yes" give reason• �
Grout: '
Nea.� SandlCement ✓'� Concrete Grave3lCement
'. Annular Space Width �� inches Water in Annular Space Yes �✓ No
Method of Grou� i'umped Pressure Poured ✓ Depth � to �� Ft
MateriaLs Used: -
No. Bags Portiand cement ' Weight of 1 Bag Pounds
If mixture (sa.nd, gravel, cuttings) — Ratio to
ID plates: � Yes _ No 4 x 4 slab �,/�Yes � No
Liner:
Depth:
_. ,..
Date Installed:
Drilling Log
Grout Tnstalled by:
Locafion Drawing
From To F�rmation . �
3 ^`.i�.�b �rCi�'�^ ,
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2;� 7� a v� r
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I hereby certify that the above infocination i.s cozrect and that this well was constxucted in accordance with reguIations set forth
by the Persoa County Health Department '
Signature of Contractor
ID# 3t-(G� nat� 11�- 3v-t��
Pnmp Installment
Pump Instaliation Contractar: � l�'e �� cve l!�,� 11i .� StaY.e Regis�arion Number. ! 4;� !
Pump Depth: ��{ D_ ft Static Watec Level: `Z � ft
Pump Make & Modei: ��lQ. [1 SE.I� Pump Size and Ratang. ��2 hp ; L gpm
I hereby certify that this pump was installed and the well head completed according to the Person County Well Rules in effeet
on this date and tha# a copy of this record has been pro�ided to the well owner.
� ,� •
Puuip Installer Signature l�� �, �,r'1 �" l_.% ��, �4` Date: j�' 3v' �� PCHD rev O1/27/04
PERSON COUNTY HEALTH DEPARTMENT
SUBSURFACE WASTEWATER SYSTEM MONITORING REPORT
� Z � � o21�J0 �� � ���
Da o Inspection Sys em Inst Ilation Date Type Tax Map Parcel #
Q6 ��r'c�'�—
Property Address
o2�Is�
Instructions: Check yes or no for appropriate items and explain inspace provided for remarks and
comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate
by "N" and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance
and monitoring items specified in the permit are to be carried out.
INSPECTION RESULTS
COLLECTION SYSTEM:
Evidence of leaks 7
Tank risers accessible, free of
infiltration and surface water diverted ?
Septic tank necds pum�ping 7
inches of solids:�_
Septic tank filter cleaned 7
EFFLUENT DOSING SYSTEM:
Required pumps present & functional ?
High water alarm operating properly ?
Floats, valves, etc. in good condition 7
Control panel & components in good
condition ?
Effluent free of excess solids ? ��
Inches of solids(pump/dose t ):�
Elapsed time readings ?
Counter readings ?
Drawdown rate:
YES / N
❑ 1
� / �❑�
� � ❑
�■
�.
�■
►: ■
1�� ■
DISPOSAL FIELD:
Evidence of effluent surfacing ? ❑
Evidence of effluent ponding in trenches ?❑
Surface water effectively diverted 7
Diversions/swales properly maintained 7
Vegetative cover maintained ?
Protected from tr�c/unauthorized uses ?
Distribution devices in good condition ?
Field free of settled or low areas 7
/
/
/
/
/
/
/
/
i
/:
■
■
■
■
■
PRESSURE DISTRIBUTION SYSTEM:
Turnups/cleanouts/valves/taps intact &
accessible ? � � ❑
Pressure head properly adjusted ? / ❑
COMPLIANCE:
Compliant
Non-compliant
Needs Maintenance
A.i)DiTIONaL CONM�ENTS:
�
■
■
REMARKS
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