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A30 142o� �,,��,1A� Ap�licallon Date: �"' ��-� 3 � 3��� Tax Map #• ' T3� Amount �aid• J � Recai Parcal �: � � � �_ �� ����; � ���� �� D��� � ������- ��.�a-�....,, w.,..,. .a�-��.n ���.n�. � APPlJCATiON Ft3R SEii1/IC�S � iF THE INFaRMATI�N IN THE APP�1C�►T[ON F�R AN IMPROVEAAENT PE�tAAIT iS INCORRE�'T. F�LS1FiEi�. CHAPIGED OR THE SITE 15 ALTERED THEA1 THE 1NIPR01/EiIAENT PERMIT AND ALITHORIZ�ITIOIV TO . CONSTRUCT SHALL BECOME INVALID. -� 1) Permit requested by: (Ownerlagentlprospec�rre ownerj:� r �� i � � Home Phone: ��c�- Sp�.-���1 Address: � i 'r •� Business Phone: 3'� c�- S n�-�3`�S + o r '7 S 2) iName and �ddress aF current owner: �a w� e c, s��� �r� /� 1 %C � . i J / ' 3) Property Description: �Lrr�fi�¢e• 3`� - lo y Townshlp �ush��Subdivision: Lot # Dire�tions to the proper�y (Induding road names�and numb rs): Ta ke �t `� 5-F w��Zr o x h o � o�-1-u r n i�-4.�1- r�r. ��.I1?�S� 4-�assell l�or-�vr r'Z- oGd : c'�P�m��rna-I-e lt� � 4) proposed Use and Structure Description: answer eaci� of the following questions: a) Proposed �[, Existing Type of Structure: �; �= �� k re s � d f,�, � Width: 1 D� . De#�th: .�`�'_ b) Numher of Bedrooms: � Number af occupants or people to b$ served: �_ c) 8asement Yes . No � Will there be piumbing in the•basement? d) 6arbage Dispasal: Yes . Na ✓ _ � Water Supply 7'y�e: Private v(new ✓ ar exlsting�]� Puhiic_, Cammt�nity� , Spring � . Are any wells on adjaining property? Yes_ No _ If yes, piease indicate approximate loc�tiori a� the 'siie pian. � � Does your pc+oparty cantain_previousiy identtfled Jur[sdictionai we#lands? Yes No ✓ PL.EASE NO'TE THE FOLLOWING: ➢ A Pl.AT OF THE PROPEiZTY OR SIT� PLAfd AAUST BE SUHMITTED WiTN THIS APPUCATION. ➢ PROPEi�TY LlNES AiVD CORNERS IIAUST BE CLEARI.Y MARKED. •, 9 THE PROPOSED LOC�4TiON OF ALL. STRUCTURES i1AU3T BE STA6�D OR FLAGGED. 9 THE SITE MUST �E RE�►DILY ACCESSIBLE Ft3R AN EVALUATlON BY THE HEe4L.TH DEPARTMEAiT S'1'AFF. . I hereby make applicat3on to the Person County Health Department far a site evaluatIon for ttte on-site sewage disposal system for the above-described property. I agree that the contents of this appiication are true and represe,nt the maximum faciii�es to be placed on the property. I understand iF the siie is aitered or the intended use changes, the pefmii shall became irnalid. , �,� �7 n Cwne o� �e�al Rea ' e � a PC�ID, rev. �6127/02 �-��, i ,�� ��1� �1.�I' �� �~ � � �LJ � � � �a�n.�n��aaTMTM-,. �aa��.� ����.���a T�x M��� � ''' P�rcel # ' S'UIbL�IVISi0t1 Ph�se Section Lot # Permit Valid for Type of Facility: # of Occupants � # of Proposed Wastewater System: Proposed Repair: �vt,�J�vt� Improve�ent Permii No Ezpiration _ New � Addition Water Supply �� Bedrooms Projected Daily Flow 6'O g.p.d. Permit Conditions: 5�°� Sin� vi��..�''� ' Owner or Lega1 Represe Authorized State Agent: Type: 9 Type: ��} Date: `E -� � �3 Date: � "d � The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the applicant/property 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 Sewage 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 Wa�tewater System (Itequired for Building Permit) * See site plan and additional attachments (_). Proposed Wastewater System: �p��-iZNc-+� � Type � Wastewater Flow �.p.d. New %� Repair Expansion Soil LTAR: .�>� g.p.d./ ft 2 Type of Facility: � - Basement Yes � No Wastewater 5ystem Requirements Tank Size: Septic Tank: ��� gal Puffip Tank: gal Grease Trap: gal Drainfield: Total Area: �.sq ft Total Length ,� ft 1Vlazimum Trench ]Depth �`� �� an Trench Width � ft Minimum Soil Cover: _� an Minimum Trench Separation: � ft Distribution Box Specifications: Authorized State Agent: � Permit Expiration Date: � Serial Distribution Pressure Manifold � v Date: o2`t 2'� '� The type of system pemutted is �Gonventional Innovative Alternative. I accept the specifications of the permit. - Owner/I,egal i�epresentative: Date: 4-17-a�3 PCHD 1 /17/2003 BUSITY FEBR�AR 2 2 � I p. BRANN I REgECCA ( EARL T. BRANN � HENRY MAC ALLEN H �pWRENCE LILLIAN OLSEN AL��N I CATHERN H• LAWRENCE 95 ApRE692 � 4s, P. 257 I � � - — � SR � � 3J� � � - R/w � N _ �- TO SR 1137 � ` NF S89'47'08"E - �_ '_ � r �— S89"52'56"E 154.97.' 30.00'�_ _ _ _ i"52' S6"E 167 .47' - --- p- - �iIF ��S gp.71' NF _ Or ROriD i�. S� - Is - - �H�SS N � ' '; � � �� a�� � �u� IS ,�► ;r r I ,�i�, ��1 �-{.e� [ a so ��P�?�, ���f 412.50' Ngg"00'03"w � rn OcJC� �`�S�P� 01/1 � � � ��� ����j� ��,.�. , , � I � . o�F � � i � � (�l, � r � � �� i , � � M cn N N o ��e r ���( .P. � �� w� � �o �, - �.�� �N / � -+� � t � li�I� � 1 rn �,�P �` �`s � la w�.J �� �� ; ; ^`\4�(,� �, ��c 4 ` ' \ i� ii i� i� i� i� i� i� �� �� �' r ' ' �� � � L� �-- , � � � a� �� � _ � , __ ____ - , �--- _ — -- –____------ IF _---- CONTROL CORNER _ �1�A 7��� ���� �� �..,..' � � � �� �i � 7��.��-��� �m.�.71 I�3L�.�.If.�I�. ��.I. PE�T� . ���E SEE A�'1"I'A�EI� P�1V F43�t WE� SI'I'� ���IT� T� I�Yap #: �� Appine�mm� ____ ��'T I'arcel # d � �- ���, l� '�ownshig . �r ` � - Subdivisioai: Sesxion: Y.ot; 'i'vme of Wa�r Saa��ll�:: Rea�ar�ffienffi- 1' ..•. Site Approved by '���� � � � 3-� `� Groutin.g Approved bp 3 1- � 3-� 4 Well Log �- t 3'�1 �Tell T .Air Vent � Hose B� Concrete Slab w��. �1��Y: �'� .- ' ' :•. , ;► .�� . ;.i. f ;:�' � Community Public l� �°5ee AttacHae� Sit� Sk�sc,�a�* Wells must be 10 feet from propertp liaes. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from anp building founda.tion. Other conditions• m � �`'�,''°L t,�` c3v� - na.a� ,�%� �2 . PC.�-ID, rev. 09/07/01 � .' ._:':- . � � � � ' �� � . ��� � �ir�� � �' � ����� IE�.�.��+,�„ ,,.,�-,: ,�,-�.-� �..� 1�7L����. .:.�.. �-t�r,ru ' N � � � . � 0 i -=;. f:1=;� � �.�. �,�i ;,,�; �- � � ..;.,,i � r F�is -��'�_ ���' ' �- � ,;,� . . � e! �r��t� 41'� � ��; T��t . . � . . - . �. ' . . . -r e ln A�+�ce Wfih `iab�e Va�: . � -- . . Sj/��► Yfa � , . . THIS S�TE�A HAS • BE�! INS'CALLF.� I1�[ GL]�PtIA►NC�. ;1NTrH �►PQl.1GABL.�. NORTH CAROL7NA 'G�tE1�AL �.STATUTES, -RLJL.E� �t3R SE�iA�GE'�REA.TI1�E�fT �D D�.S�L, - AND ALL CaNDt170NS� . OF : TI3� I�IPR[3YE�flE�IT� P�it AI�ID. •i'•DNS�Rl1C�I�I�f ' •ALJ'iT i0 ON� � ' . . . ' , ►�� � . .� - �:�� � `� . � �: . � ��� s� � � � � � � � �� --� ' ' � °� . - . i;�u� esr- �� �� S _ �r�: �r`�� `� �� %�' �-0'3 � �--s 1 c�cn.> S�C� I`�� FCr�ii). r�v. a712n�C2 � . . . . • • .' . � , � . ;s=. • �tT � ' L�r�1 i •V ��� 1i77���..�i� `'iV�' ��� �i i— — � - � • • ' • T� Niap � �� F��i �- • . ��ystent Type (T�fiie ��� . Qyun,�f,�,pQitc�rrt S�on ' .. Addr�s�Locaf�n � S�se � L.� � � . . . . , . . , 0 Barnette Well Drilling Inc 836 598 9275 01/13104 05:33P P.001 `-�..��,5� ������_� D�H�arOD� �►� . � r. r �` �j 'i./ � `� � �JS. � UU�IIX)l`! �"lir" r'l'! C �. ' • �'..rr,n^v�i �r^�c�+�t�.��'+�'h.�•� SE.cnI� Ir � ��.e�.n tC:ll7t � � 1 •%�'�ti. — � •.� Crout Lo� � Owner: ��fY+� l�ii/� Tax Map �a Parcel #!�/�. X,ocation• f7�, �_��ef���• Subciivision• Lot # � � ,, I; �� ��� Well Cons�n�ct�o�n � I7istance From nearest [�roperty Linc (Minirnum lp feet) Dis�ancc from Septic Systcm (Minimum 60 feet) �, �� _ Totai Depth_ 1 clD ft Xield: �C� GPM Static Watec Lev�l: �_ ft Water Bearing Zones: Deplh (�[tl�1 ft �. � ft ,�Q��._, ft ft C�s�n�: . Depth: From G----� to G�� ft• �7aamet�r: �Thr in Type: Galvinized Steel „�.��_ W�i�ht: Thickness: �_ ��eight abave Ground: � in I7rive Shoc: �y Xes No Any problems encpuntered w�fiile sctting casing? �Yes �Na If �`yGS" �ive reason: , Grout: Neat:.� SandlCement � Concrete GravcUCement Annutar Spaee Width inches W� cr in Annular Space Yex No �Vlethoci of Grout: Pum�ed Pressur� �Poured Depth �_ to � Ft. . Materials U:+ed: No. Bags Poztland ccrn�nt •�`" ` Weight of ] Bag ��, Pounds z� mixture (sand, gravel, cuttings) — Ratio ta �D plates: � Yes ,_ No 4 x 4 slab �`Ycs � No Arillin� Log Lacation Drawing �rvm To Formation � ' , �,� � � . . ��.�� � �J� 1 o� �. y�,.� � +�°1S � v I he�eby certify that tttc �ybove information iti cozrect and that this well was eonstructed i� accordance witt� regulations set f�rth by th� Pcrson County i-�ealth Taeria t. . Signature of Contractor ID #.x�'1��� --- Date I�/�-,�,Lr/ F'CHD rev Q9/30/(!2