A30 122Tax Map #:
PERSON COUNTY ENVIRONMENTAL HEAL-TH
SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAY
Paroel #
Zoning Townshlp
Appiicant• � � ��)i S
LocaUon: �"1. c)01.���.� � L i" `� j� l.._c.�K.. �J
v
Subdivislon: �� � I��� �� SecUon: Lot �
Improvement Permit
A buildinq permit cannot be issued with oniv an Improvement Permit
New � Repair Addition Type of Strudure S� Water Suppiy ��(�,
# of Occupants t�" ,# of Bedrooms � Other
Basement? � Basement F'uctures?
Projected Daily Flow: 3(E,((�q.p.d. Permit Valid For. � Years ❑ No Expiration
Proposed Wastewater System Type: 'T-�c ,�-�. �(1�M.�'�,� e .1
Pump Required? � Yes 1,i1Vo ��
Proposed Repair : 171,c.v�r-�;��QL_h_�a �fiy�Z�
Permit Conditions�—
Owner or Legal Representative Signature: �� � Date: z-!/- O Z-
q � <
Authorized State Agent: W � � � �. Date:_ �����'S
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit
holder is responsibte for chedcing with appropriate goveming bodies in meeting their requirements. This site is
subject to revocation if the site plan, plat, or the intended use changes. The Improvement Permit shall not be
affected by a change in ownership of the site. This pertnit is subject to compliance with the provisions of the
Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code.
Authorization To Construct Wastewater System (Required for Building Permitl
Type of Wastewater System Wastewater Flow: ��g.p.d.
Facility Type: � New �ir DExpansion ❑
Basement? 0 Yes GLPd� Basement Fixtures? Cl Yes Q.DIe—
Wastewater Svstem ReQuirements
Septic Tank Size: ��� gallons Pump Tank Size: �� gallons
Total Trench Length:1- � feet Maximum T�ench Depth: �_ inches Aggregate Depth:�2in.
Maximum Soil Cover. � inches Trench Separation: ,� Feet on Center
Other.
Permit Expiration Date: J
,
Authorized State Agen . � Date: �J'c3��
The type of system pe itted 0 does ❑ does not differ from the type specified on the application. I accept
the specifications of this permit
Owner/Legal Representative Signature: �c�Gu�--- Date: �-//-7� Z �
PCHD, rev. 11/18I99
AppUcation #:
Tax Map #: c3
Parcel #: , r'�-
• Person County Health Department
Environmentat Health Section
SITE SKETCH
,��� ; �l �W I..�-�� 1--�-�C
SubdivisioNSection/Lot#
�Q,�les v ,s -
Applicant's Name
Authorized State Agen
5:�3fl-�
Date
Svstem components represeni approzimate contours only. The contractor must f lag the system
to
the insfallation to insure that proper grade rs macnra�nea.
l�, ��f��
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_ � �
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Scale: � � � = I6D'
PCHD, �ev.10112199
PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: � � Parcel # � �
Zoning Township � � �
� f
AppUtant QJ� `e �jt� 15
� �\
Loeatlon: � �S �i.t�'�'�. �
"�l�r�
�/�� � `�l�t�� �'L Sectlon- ��
Subdiv(sfon•
Tvpe of Water Suuplv:
Requirements•
Well Permit
✓ Individual Community Public
,
Site Approved b 5
Grouting Ap ved by ' "a2-
Weil Log
Weli 7ag �
Air Vent
Hose Bib
Concrete Slab
Well Driller: �
,
Well �Approved By: �
Date: � � � �-
**See Attached Site Sketch*�`
ells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Welis must be at least 25 feet from any buiiding foundation.
Other conditions:
PCHD, rev. 11/29/99
. , .. . . • • ���� /� J����• V � - • , " • .
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Zoning: Township: ' �
3i�bdivision: ��V =C� Q`v�' �:rt�;�;: .. Sectlon: � Lo� l,
Appitcan� ��"�� �R�tn�
Location: `���' I' '� f � � "
e
Qpt-�C�ti41'i ���'1'il l$ �
_ ,
. _ System '�ype (In Accordance With Table Va): �°�
�'HIS SYSTEM HAS BEEN INSTALLED IN COMPLlANCE WITH APPLICABLE NORTH
CAROLINA GEAIERAL STATUTES, RULES FOR SEWAGE TREAT11AEiVT AND DISPOSAL,
AC�D ALL CONDITIONS OF THE 1MPROVEiWENT PERMIT AND CONSTRUCTION
AUTHO ON. -
� e�
� �'��a �
Authorized State Agent � Date
�
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IE��.a-��� ����.Il ����.Il¢II�
Owner. `
Location:
Subdivision:
D� OD � _�d� �/
� a� !_�:�;� � `k 1���/�Z�`.
Do�-0 D��l - 3—� -��-
Well Log
Tax Map
Lot # GY
Parcel #
Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from Septic System (Minimum 60 feet)
Total Depth: ��_ ft Yield: � GPM Static Water Level: ,,�� ft
Water Bearing Zones: Depth � S�-_ l ft� ft ft ft
Casing:
Depth: From C% to � 7 ft. Diameter: ���� in
Type: Galvanized Steel �
Weight: 'clrness: ,/ Height above Ground: �.s in
Drive Shoe: c/ Yes No Any problems encountered while setting casing? _Yes
If "yes" give reason:
�
Grout:
Neat: SandlCement Concrete GraveUCement
Annular Space Width inches Water in Annular Space Yes
Method of Grout: Pumped Pressure Poured Depth to
Materials Used:
No. Bags Portland cement Weight of 1 Bag Pounds
If mixture (sand, gravel, cuttings) — Ratio to
ID plates: Yes No 4 x 4 slab _ Yes No
No
Ft.
Drilling Log Location Drawing
From To Formation �
t� 7 � ��; �-� � �
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I hereby certify that the above information is correct and that this well was constructed in accorda.nce with regulations
set forth by the Person County Health Deparkn nt
Signature of Contractor (, �/ ID# 3D?-�( Date �—l� �D'
PCHD rev O1/16/02