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PE�SO� COUNTY HEALT DEPARTMENT
,, WELL AN7 SEWAGE SITE, LOCATION IlVIPROVEMENT PERN`lIT'
Tax Map # Parcel #
Zonin� _ _ Township f _
Owner/Contractor
Location/Address
Subdivision Name
Layout
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SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area Size of Tank
SFD Mobile Home Size of Pump Tank �
Business # of Bedrooms Nitrification Line _
Max Depth Trenches �
Pernut Void after 60 months. Permit Void if not in compliance with zoning re ion .
Pernuts may be voided if site is altered or intende use changed.
Well and Septic Layout by � ' �-
Comments:
Date Installed by
by,
WELL SYSTEM SPECIFICATIONS
�ividual�Semi-Public Required Slab �
�blic Replaceme t Air Vent
te Approved �� Required Well Lo�
ell Head Approved Well Tag I
-outing Approved
. . � � .•, � _ _ . .. �
Date �� Inst ed y ��,�,M C Approved by
This report is based in part on information provided the homeowner or hisJher representative in the application submitted for this permit The
environmental health speciali� is not responsible for false or misleading info�rnation 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
statemenis provided to him in the applicatioa Neither Person County nor the environmental health specia(ist wazrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable: c:�amipro�pennitsam O 1/95 rev.1.0
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PERSON COUNTY HEALTH DEPARTMENT
.� WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERNIIT
' Tax Map # %�c�j� Parcel # � 2.
� Zoning Township �� O �'IL
Owner/Contractor
Location/Address
Subdivision Name Lot#
Date 1-1 y - 9 �'
S.R.#
A 1427
SEWAGE SYSTEM SPECIFICATIONS
Lot Area
Mobile Home
# of Bedrooms
�-
Size of Tank�
Size of Pump Tank_
Nitrification Line 1
Max Depth Trenches
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Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or intended use changed.
Well and Septic Layout by � �
Comments:
Date
�
Site Appro
Well Head
Grouting �
Comments:
Date
Installed by.
Approved by
WELL SYSTEM SPECIFICATIONS
Semi-Public
Installed by
Required
Air Vent
[i Reauir�d
Approved by.
This report is based in pazt on infonnation provided the homeowner or his/her representative in the application submitted for this pemiit The
envirorunental health specialist is not responsible for false or misleading infotmation contained in the application. The environmental health specialist
is also not responsible for concealed conditions on the propetty or for statements in this report that may have resulted &om false or misleading
statements provided to him in the applicatioa Neither Petson County nor the environmental health specialist warrants that the septic tank system will
continue to function satisfadorily in the future or that the water supply will remain potable. c:\amipro�pe�mitsam O1/95 rev.1.0
ORIGINAL
Aqalic�ation Date: � " � I —bC�
` Amount Paid: �S, OO
Receiat#: allo Xi
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LJ 1 ' � L ,�e�:
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Person Countv Health Department
Environmental Heaith Section
APPLICATION FOR SERVICES
Tax Maa #: � 3 O
Parcel #: < < �
C��L �� c�.n�n
Saco {�5 -�D f Yl cc�
�'03 � 1� D� 1
1) Permit requested by: �Own r/agent! rospective owner):_
Home Phone: 33 �03 — �D � '] Address:
Business Phone:
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Townsnip: ��� �r� �!� �
ad na es and numbers): �-t-��— ,Qc�
c� �ti f 1_ C�
2) Name and address of current owner:
3) Property Description: �ot size: l.0
Directions to the property (InGudir��rc
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.�i� �, 9 /
4) Proposed Use �pd Structure Description: answer each of the following questions:
a) Proposed U; Existing ❑ �/�
b) Stick Built �, Modular ❑, Singie Wide ❑, Double �de [�'
c) Number of Bedrooms:� d) Number of occupants or people to be served: o�
e) Basement: Yes �, No C9'ff yes, # o asement fixtures:
� Garbage Disposal: Yes ❑, No � d v
g) Dimensions of Proposed Structure: Wdth: c�0 Depth: �
5) Water Supply Type: Private u"(new � or existing ❑), Public ❑, Community �, Spring 0
Are any welis on adjoining property? Yes ❑ No ❑ If yes, location
6) P1ease Indicate Desired System Type: (systems can be ranked in order of your preference)
vConventional _Modified Conventionai _ Alternative _Innovative
Other (specify):
CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION
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I hereby make application to the 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 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 as applicant, I am responsible for identifying and marking property lines, comers and making the site accessible for the
personnel of the Person County Health Department to conduct their evaluations. I understand that I am responsible for notifying the
Health D a ent if my pro tains y wetlands as designated by the Army Corps of Engineers.
«...-.. �- // - Ov
' Owner or e epresentative Date
PCHD, rev. 10/12/99
PLEASE SEE ATTACHED PI
Taz Map #: ��D �
Zoning �� Ve�rM� �
Appllcant:
Locadon: �'"I I �/ 61 1� / I�'c�l� 1
Subdlvision:
FOR SC�tL AREA AND SYSTEM LA'
Parcel # � � Z
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SecUon:
Improvement Permit
Lot:
ermit
e���1,C1 vi ,./�
New ✓ Repair _ Addition _ Type of Structur Water Supply�� I%�'C.�i
# of Occupants � # of Bedrooms � Other -
Basement? ,�Q_ Basement Fixtures? � _
Projected Daily Flow: �� g.p.d. Permit Valid For. Cl'Five Year< ❑ No Expiration
Proposed Wastewater SystemType: COt��/`�(/(,f (Dl/�G(il �r� U� C`�ll�l���i �� r��`��
Pump Required? Yes�Pl��
. �
Permit
(1...����
Owner or Legal Representative Signature: Date:
Authorized State Agent: ,���� � .� ��/V �' ► _ Date: �— �J� —�V
The issuance of this permit by the Health Department in no way guarantees the issuance of other ^ermits. The peRnit
holder is responsible for checking with appropriate goveming bodies in meeting i-;:ir require--:��nts. This site is
subject to revocation if the site plan, plat, or the intended use chang�s. The Improvement Permit shall not be
affected by a change in ownership of the site. This permit is subject to comp[iance with the provisions of the
Laws and Rules for Sewage Treatment and Disposal Systems of the Nocth Ca�olina Administrative Code.
Nu'�i���;;x�ii�,; i o Cor�;=:ru:�: `:: �...���ti��:�r S�s����n ��aaui���u for Ecsildin� �err.iif
Type of Wastewater System �� � Wastewater F1ow: �g.p.d• `(/��� �� (f �
Facility Type; ?J YrL{�V� i,�� CILI�-� New I�' Repair OExpansion ❑ ��%/'��' �Y
Basement? O Yes o Basement Fixtures? 0 Yes CB'�lo
Wastewater System Requirements .
Septic Tank Size: ��T gallons � Pump Tank Size: /�! � gallons
Total Trench Length: �_ feet . Maximum Trench Depth: � inches
i'1+1 i V1 I 4'l�ll,(.VY1
N{�cirflar�-Soil Cover: � inches Trench Separation: � Feet on Centei
Other:
Aggregate D�pth:�in.
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Permit Expiration Date: ��"✓ �� b� .
Authoiized State Agent: �wl/i/�%F.P/� � LP. 4-1G2����vl Date: �—�( (.1/
The type of system pe; �nitted ❑ does ❑ does not differ from the type specified on the application. I accept
the specifications of this permit .
OwneNLegal Representative Signature: Date: ,
PCHD, rev/ 10/'t2/99 '
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Application #:
Tax Map #: v
Parcel #:
Person County Health Department
Environmental Health Section
�,� � C�q� � V��n; �--y � SITE SKETCH
rl-�-i�-`f� C 2�l � c) ��VI �I�il �� .
Applicant s Name ` Subdivision/Section/Lot#
� ,nE �r� .� � �?� 4� �- 3I -�D
uthorized State gent Date � .
System components represent approximate contours only. The contractor must flag the system
prior to beginning the installation to insure that proper grade is maintained
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S� S,R, 1165 C60' . ROW)`�,; ..`. :,
Scafe: � �I U
PCHD, rev. 10/12/99
PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
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Location:
Subdivision. Secdon• LoC
Well Permit
�ae of Water Suaalv: �ndividual Community Public
Reauirements•
Site Approved by v7"� 10�a� fl3
Grouting Approved by ✓3� �o- �3'c.�3
Well Log ✓�H i o�a$-a3
Well Tag
Air Vent
Hose Bib
Concrete Slab
Well Driller•
Well Approved By: Date:
**See Attached Site Sketch**
Welis 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:
PCHD, rev. 11/29/99
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OwneX: G � � �r- "1';L� iYl;ip �v_ 1'u•ccl «��
Location: � h ',n_ �
Subdivision• Lot !f ^ _
l���cll Cvustruc:Ciou
Distancc I'roin ncaresc 1'r���crty Linc (1vTinimum 1(: •k�e:t) _."._�___._._
Distance Eroni Scplic Sysceui (Ivizniinuni (i0lcct) f
Total Dcptii: /� V ft Yicld: _�_ GPM S�►tic W;ilcr L�vel: �„�: _ l�
Water I3c:uinb Z� n� Dcp c h l l.� tt �'t _:�� _<<
Casiub:
Depth' From �i lo �� it. l�iaiuctcr: _,�� in . .
Type: Galvatiized Stc�l � 'r `
Wei�ht: _J � ".!'hickness: ! n' � � Ile:i�;1�C abovc Ground: __/ � iil .
Drive Slioc:: ./ Xc:s No F1.iiy problcros cncounccc'ccl wliilc: sc:ltin�; c:isiu�? __ Y�s '�No
(f'�es" give reason: _----------
Grout:
Tt�at: Sand/Cement �' Concrcle GravellCement
A�u�,ular Sp4cc Widtli �, incli�s V�atcr in �A.,�inu�nacc Yes '� No _�
Mclliod of Grout: Puni��cd �'ressure: ' 1'oure:d Dcptli `,.:to rt. .,:�
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