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A30 143Application Date: J ") `F-0 Amount Paid: 2on . 00 Receipt #: �7 ��T �� 0� � �d3��. �� 7'� � ��'?,�� Jl �� .� � �a s�>'�iac�ov.a�•-+�'++ c+v_a�m� ��min.��a APPLICATION FOR SERVICES Tax Map #: �� Parcel #: IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED, CHANGED, OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. 1) Permit requested by: (Owner/agentlprospective owner): 1Sw er Home Phone: 33G � 599-7730 Address: I S a 1 • Business Phone: C , 7S 2) Name and address of current owner: �'}'�'1L`fr� �-Q.(.t)C'�►'C'� I 3 t� ie �� S� orC �i SW 3) Property Description: Lot size: �•aC�Township: �� o� k ubdivision: Directions to the proplp��(In YludWg road�an�s aAd numbers : W ��'h � c h��f t C �E'�-� rs GL o �/�. Vt�'� t o n Lot # — � 4) Proposed Use and Structure Description: answer e�cAh of t e fo lowing questions: i 7� a) Proposed _, Existing _, Type of Structure: IVIo}� i� ��'1e Width: �8 x Depth: b) Number of Bedrooms: Number of occupants or people to be served: _� c) Basement: Yes_, No` Will there be plumbing in the basement? d) Garbage Disposal: Yes _, No� 5) Water Supply Type: Private �(new 1�or existing_), Public_, Community_, Spring _ Are any wells on adjoining property? Yes_ No� If yes, please indicate approximate location on the site plan. 6) Does your property contain previously identified jurisdictional wetlands? Yes_ No� PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED 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 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.,., Owner or Legal Representative �--! 3 -0 3 Date PCHD, rev. 06/27/02 � �—��, ; , �� .-.. �.^ � � � � � � I��aa-�� .IL IFZI��.I1�Ila / T�x M�� P�rcel # S�uhelivis�ion Ph��s�e Sect�ion.Lot # Applicant: ��f�-�`Qv''✓1 �U�l�e/lC� Location: _ _ . .� _ , n , n r� _ n , _ � i , �\ Permit Valid for �Fi e YE Type of Facility: # of Occupants # of Proposed Wastewater System: Proposed Repair: �v_ Permit Conditions: Improvement Permit No Ezpiration z• New �Additi Water Supply �e � Qoms Projected Daily Flow � g.p.d. � �✓ZrrV�2 � Type: � G ,. �'11-e- Type: � ' L��--{-- 6� ` �; Owner or Legal Representative Si e: �' Date: %- �03 Authorized State Agent: Date: � � � The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the applicanbproperty owner to in sure that all Person County Planning and Zoning and Building.Inspections requirements are met This Improvement P.ermit 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 5ewage Treatment and Disposal Systems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health 5pecialist 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 (_). ��'�1 �2f' �L 0 r Proposed Wastewater System: �✓(��tZ ��- �Z -F� _ __ New � Repair Expansion _ Type of Facility: � �i� . Type�lLL � Wastewater Flow �g.p.d. Soil LTAR: � g.p.d./ ft 2 Basement _ Yes '� No Wastewater System Requirements Tank Size: Septic Tank: I�al Pump Tank: gal Grease Trap: gal Drainfield: Total Area: 1� sq $ Total Length �D ft Maximum Trench Depth �� , in Trench Width � ft Minimum 5oi1 Cover: �_ in Minimum Trench Separation: ( ft V�+ Distribution: Specifications: Distribution Box �e �� ; Authorized State Agent: _�� Permit Expiration Date: i� Serial Di �� v�e. Ci� Manifold Date: � �j v � The type of system permitted is Conventional �Innovative Alternative. I accept the specifications of the perxnit. Owner/LegalRepresentative: � Date: �] /C�'d 3 PCHD7/30/2002 v v � � � � � � � � Z rn n � IF CONiROL CORN�.R Z � ��.� �5�-- 0 o, o� � � � v� �'-�, r�v� W J 'QQ � � ` ...J � � CATH�RN H. LAWRENCE � 1.3+'-" �� D_8.114. P. 52 ��,�,5-�-�,�� -�`�' - �c��c� � r,�e�< ��c�-��,., .--._ _ _'--�r, IF S� R '_ `i � l�- D� �: � ---�__� )37 ___ is�� —: -- _��'_ ��W _ ,--- _ .�,� NS ' _ _ ---- _ Lin �. � _ S79°18'27��E NS -� -- �_ _ `� ` 0 110..70' S7g ^2g � 00'�E NS � - �_ _ IS � 96.16+ - _ - __! - - --._ _ o ' ----- __�__ o -�_ Tp S� . L� �_ - _ M I S J �."� � ' � - ' . �. D - �� 5�,(� � � u � � _ _ � r � � i�o �,� � sd-�,� j l =50 � � T � � �!✓� �r , �, �'�S � N � � � E _ ��,� s�,`ls . �� , � w � S-� - �; I �I � � N �� - � � p M so� 5 � � . 0 36' � �od r � z �� ( � s�� -�- � o �s - 3/ n M � _ � �i � it . (n IS ! D' 2�6.89� � N79`21'29��W O - IS _ . � . CATHtRN N• �AY p.6.114'_P' . . . _ � -� ,--4 �� t�� 1 � f � _ ' � � � �� iG�i��'�-te�n'7L'Sffi_Q �-� ��i.��i.li]L . . � �.1�.i�...{ ��SY-�� ' ^ ��„�JJL:J J� G�� YJC1L d �� Uil " -• :�.�s� Y O4J � �� !p #: � � �a'ZtCP�. � �_ _G � '�O�PIIS�lE�R �� ` - '�Qr✓1 G^aLc/�✓t. C�.� . Snbdivisio�: _ Sea�aon: �-.o� .� � ,; ,� : )�� ., :c-- . �. ,� :: -� � • a r �� t a u � � � � l��a�nrr�ffiea��• . Site .A�prov�d by � [ `"f—D3 Grouting�i�mved by We11I�ag � WeIl Ta Air Ve�.t • � Hose Bsb ' Concxete Sla� _ � � �0�(..� �-+/ l , � v�r- �R►"��P,� � . �,� 1��C.�. Ct ' ' kt - E' ;1 r, ':I', �.�� i!: : , - t .. � i I �'! - �: � � c � i. . - :r . _ '�ee l�cffaes� Site S�cal��` Wells must be 10 f-eet from property Iiaes. WeIls must be 140 feet from septic systems• � . WeIls nzust be at least 25 f�et from anp buildin.g foundation. �� i��. •� • •�� PC�f�, rv. 09/Q7/01 ``�� . �� `�1,1a � �r �� Jl � ��.�.a-�� .11 I�33L��.7I-�. Applicant: �a��- s�, �.,��- � Locafion: ��5 � �.,�:.�GQ�z -� � � i�� . 'i�, �;� �., � � - ;' , , � ` �' - T��x Nla:� � P�:r�cMel '; S'U'h f�!I V I�S�I O ld Ph�s�e-Sec�t�ior� lot +� System Type (In Accordance With Table Va): � � THIS SYSTEM HAS BEEPI INSTALLED IAi COMPLIANCE VVITH �PL1C�►BLE NO TH CAIiOLiNA GENERAL STATUTES, RULES .FOR SEWt9►C�E �TFdEATMENT AND DISPOSd�L, AND ALL COIVCDITIOfdS OF TIHE IIIAPROVE�lIENT � PERNi1T . AND CONSTRd1CT10N . . . .. AUTHORIZATION.. � � �� ' _ . . � _ �$r v3 . -. � . .. Authorized State �A ent � . . � � � . ' : -Date � - Instailed By: \ �� e Date: 8-C� �� . . + . e �f8'I `7�x ls �� " >�-�= �'' - PCHD, rev.. D7/29/02 S��C TAI�E� 1AiSPECTI��! CiiE�9CLlSi (i'�pe i[ -� Tax Map # A� Paresl # I�3 System Type {Table Va) �G Owmer�Applicant� �a �n, ( n.�� Subdivision AddresslLocation ��,s � ��k�Q� '� � � SeclPhase Lot # �oti ��4 r�.,lx on� St2te 1D/date 5-�3-3a�� s-�3-�3 Capaciiy. '� - � �� . gal. Tee and Fiter Ba#fle � Sealant Riser if ap licable Tank Outlet�. Seai Permanent IVlarker � Ptamp Tank ISealant I Riser 0 , �....r, � Che�k Valve/Gate Valve . - nti-siphon o e .� Floats/Switches�� Alarm visable and audibie) Electrical Components Rate gpm Approved Pum Model Block Under Pump Pump Removal Rope/Chain Dis#rib4at6on System Serial Distribution ' ressure an' o Low Pressure Pipe • Appr. Pipe iViaterial and Grade Valves . �3 Trench Width ft. �s Trenct�. De th 1� fn. � Trench Length � ft. Trench Grade Trench S acing �-� Rock De th and Qua(ity � Dams/Ste downs etc. � � � Pressure Laterais � Hole Spacing o e �ze � � p Pipe Sieeve . - � � � Tum-ups}Protectors � �Requi�d Se�aclss � From Welfs �. � „a� Frnm Property lines � ..� c-� _ 5vuciuresrdasements.:: ° � itc es � rainage ays - . . . � : . . SurFace` Waters - � - Pubiic Water Supplies N 4 Vertical Cuts (>2 fE. . Water Lines Vehicle Traffic Easements/Right of W< Othe� � Easements Recorded . e e perator ni Tri-Partate Agreement Coonmerats � S-t�3 � _.__ . __ . pchd rev. 3/13/�1 0 BarneYte Well Drilling Inc �36 598 9275 08t15t03 09:26A P.001 �� ` .� �� L"JllllWl�nlf �lJ �� 7 ) �..,��' � � � �� nF� � I`/ �`-� � � _ ��`-� ��im•�vn •rt-�a�tarn-n..cr3,:ir.n.�frn�� 1i��.c+�.��.�{n VWl�3 �=+�+�� ,,, � 'L �` —G� /� G�'UUt LO�' � �wne�r: �—�C'� ��C- t'`,�� = •�' T.�x Map� Parcel #.�,.� x..ocation: ' 4 c Sutxlivisio�: �� Wel1 Construction Distance From neacest Pmperty Line (Minimum JO fcct) !� I]istanec tiom Septic System (Minimum GO feet) �� Total Depth: i{LG ft Yield: �G GPM Static Water Lcvel: .� �S ft _ W�ter Bearing Zones: Deplh Q� ft l�� ft ft ft C�sa��: .Depth: From � - ---_ t4 � ft. Diameter: � -- in Ty�e; Gafvanized Stccl �' Weight: Thickness: �_ Hcight :�bovc Gcound: l� in larive Shoc: ✓ Yes � No Any problems encountered w�iile setting casing? Yes !`No �i' "ycs" �ive reason: Groat: ` � Neat: Sanc�/Cement Concrete _ Gravel/Cesnent � A�nular Spa�e Width ._. inchcs Water in Annul�u- S�,uce Yes No N�ettyod of Grout: Pumped. Pressure Pvured �- Dcpth �_ to � Ft. Materials Uscd: � ` No. Bags Portland cement Weight o1' ] Bag Pounds � �� • If mixture (sand, gravel, c�ittings) -- Ratio to /'}� � zD piates:/ Yes _No 4 x 4 slab �'SCes _.�,No �'� � Drillirng Log i,ocation Drawing k'ron�. Ta Formation � �� . G � / a `. C L�� ' .� - � V� � ...�.� (�. Q� �� I hereby certify that the above informa�ion is eorrecc and that this welI w�.s constn�cted in aecordance with regulations set forth by rhe Persan County Health Dcp.lrtment. Sx�atuz�c ul' ontractor _ _ � ID # �� att• �"1�� " -- PCHD rev 09/3�}!02