A30 144Apalication Date:���03
Amount Paid: �
, Receipt #�
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APPLICATION FOR SERVICES
Tax Maa #: �`3 D �-�
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IF THE INFORMATION IN THE APPLIC/�TION FOR AN 1MPROVEMENT PERMIT IS INCORRECT, FALSIFIED,
CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PEgtMIT AND AUTHORI?�TION TO
CONSTRUCT Sl-IALL BECOME INVALID. . � �,
1) Pertnit requested 6y: (Ownerlagent/prospective owner):,
Home Phone: ,33 (v -�"'99- �GBo 2- Address: �
Business Phone: __ �,¢
2) lVame and address of current owner.
3) Property Description: Lot siz�:-' 3s A �Township: �
Directions to the property (Including road names and num
,,. . _ _ , � ,.._ �iz _ / .� r B.�
�P! /v_�: � �S-tL/
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</
/y ���. Lot
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4) Proposed Use an Structure Description: answer each of the following questions: , ,
a) Proposed Existing , Type of Structure: h�n �.� e Width: 60 � Depth: -2�
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 c/
5) Water Supply Type: Private �{new_ or existing�, Public� Community . Spring _
. Are any wells on adjoining property? Yes_ No �If yes, please indicate approximate location on the
site pian.
6) Does your property contain previously identified jurisdictionai wetiands? Yes_ No �
PLEASE NOTE THE FOLLOWING: �� � � �.O ,�,C�% -�r'y�a�-�
➢�► PLAT OF THE PROPERTI( OR SITE PLAN MUST BE SUBMITTED WITH Tti1S APPLICATIOId.
➢� PROPERTY LINES AND CORNERS IVIUST BE CLEARLY MARKED.
➢ THE PROPOSED LOCATIO(d OF ALL STRUCTURES MUST BE STAFCED OR FLAGGED.
➢ THE SITE MUST BE REEIDILY ACCESSIBLE FOR AN EVALUATION BY THE HE�►LTH DEPARi'IUIENT
STAFF.
I hereby make application to the Person County Health Depa�tment for a site evaluation for the on-site sewage disposal
system for the above-described property. I agree that the contents'of this appfication are true and represent the maximum
facilities to be placed on the property. 1 understand if the site is altered or the intended use changes, the permit shall
becorne invalid.
, .<.v-,u,
Owner or
Representative
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Date
PCHD, rev. 06l27/02
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Applicam
Location:
T�x �Ji��C� i �' ' �,��c. =.I :' ' �
S�u�h�� iv��s�i��a
PLr���.��'Se�ctio���:�L.at #
/ �prmvea�e�at Pea�t
Permit Valid for �/ �ive �'�ars. I�Tq �pirat.�an � * � ;,��
Type of Faciiit�: �'_-.,., ��' y./f.e�/��-p-� New 1��ddition ��ier �upply _ y��r/
# of Occupants �# of B ooms 3� � Prnjected Daily�Flow �_ g.p.d. � �
Proposed W�tewater System: es� ' � . Type: �'� -
Propos�ed Repair: � , . . � �- Type. �a
Pertnit Conditions• �
Owner or Legal Representative
Autharized State Agent:
X
r
Date: �-l�' L� � s�
Date• 7�/ -o
The issuance of tbis pernut by the Health Department in does not guarantee the issuanca of other permits. It is the responsibility of the
apPlicantfproperty owner to in sure that all Person County Planning and� Zoning and Building Inspections requirements are met TLIs
I�pravement Permit is subject to revocation if the site pian, plat or the intended use changes. The Improve�ent Permit is nnt affected
by a'cl�ange in ownerahip of Yhe property. �his permit was issueai in compliance witi► the provisione of the North Carolina Zaws and
Bules for Sewage Ti�eatntent and Disposal S`vstems' (15A NCAC. 18A .1900). Neither Person County nor #he Environmental Health
5pecialist warrants that the septtc t�k syste� will continue to funcllon satisfactorilx an the future or that the water supply will reraain
pota6le. � •
�A�tllo�ation to Co�Si�uc�'PVast�`�a$e�' Sj�steail ��teqnired ior �uilding Permit) _
* See site plan and additfonal attachments ( 1 ).
rroposed wastewater syst�m: ���t de�v�o�t� TYPe � Wastewater Flow �� .,g.p.d.
New ✓ Repair F.xpazs�' on � p �o� I.'TA�t: �7�' g-P.dJ ft 2
Type of Bacility: 3/�/���/� ���� �SiGf.Cac� Basement Yes v1Vo
Size: 5eptic Ta�uk: � gal
field: 'Total Area: : /3D p sq $
i�astewater Sy�tem Iaeqairements
,. I'u�p '�ank: --� g�l � Grease Trap: —, gal
Total Length �_ ft 1Vluamu�a'Trench IDepth 2� in
'�rench �adth � ft 1l�iinit�aaim Soal Cover: ��, in
Distribu#ion: � Distrib�tion Box Serial Distributian
Minimum Trench Separation: �_ ft
Pressure Manifold
Au#}aor�ed State Agemt: -� � �C� . ' Date: � .- �
Pennit Expiration Date: Z-/' S- � U� �
The type of system permitted is �ventional Innovative Alternative. I accept the specifications af
the permit. ' � ' . .
Oerner/�e��l ��r�se�tsttave: X� � " Date: �/�S- L o of�
� � PCHD7/30/2002
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SITE PLAN
Name ," ^
Subdivisi �
Authorized ta.te Agent
1 �-I �
Tax Map # �36 Parcel # �
Secrion/Lot# �— �
� .f, '-�o �
Date
System compor�ents represent appro�rimate cor�tovrs only. The contractormust �lag the system prlor to beginnrng the installation to
insure that propergrade is maintained,
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S81'25'39"E
TRAc�r e
3.52 ACRES
EXISTING
EiARN .
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445.U0'
222. so'
.. I
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v,�: e o� �� I�'�,Q ��'Y .. I
N O I �� , l��J �� "` � 9�
w 36 - � �
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� I ' pRAIN-FIELD � � �
� I � � WOODSLIN��'��
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N81'25'39"W
Scale:
/�=�D �
_„ 222.50'
445.00'
(TOTAL)
0
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COkNER
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32.45'
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PCHD, rev. 09/12/Ol
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WELL PERNIIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map �3� Pazcel
Applicant: �
Subdivision:
LOC�lOri: �y
� � � Township:
Type of Water Supply: �Individual Community
Reqnirements:
Site Approved By:�
Grouting Approved
Well Log: t
Pump Tag: n�te6
Well Tag:
Air Vent: —�
Hose Bib:�
/!,
! /�
l
Casing �-ieight: J �
Concrete Slab: ^- s X ^-S' � �r �"'
Lot # ,—
Public
�6 Liner:
c� - �Installedby: �.on/' •�c/ Gc�i�;v�wlS�v--
� Depth set: 3 �
Grouted: l - � �- o
Date: ! 1.- ( � o �
Water Sample:
Well Driller• �9-�i/�,�'li✓ ���.�i,4yJ��'
� . ,
Well Appmved by: Date: /d "�� D�
****See Attached Site ketch****
Wells must be 10 feet from property lines. :r
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
,
s,:
�
PCHD rev Ol/27/04
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� �rnv�a a- �m �rn.a�n. � �rn. �.�. � �� �.r�.�. ��
Applicant:
Location:
Tax M�p � � P�►,rcel #
Suhciivision
Ph�se Section: Lot #
# of Bedrooms
Operation Perm�t
System Type (In Accordance With Table Va): �
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT � PERMIT AND CONSTRUCTION.
AUTHORlZATION.
Aut riz State Agent
lnstalled By: r /
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ate
Date: /D����D �
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PCHD, rev. 07/29/04
S�E��'iiC �' ��C I�i��IE��N C�fE��.lS'�' (T� id -1�
Tax lUlaQ-#� Parc�! # � Systesn Type (Tat�ie Va) .
Owne�lAQQ icar�t � Subdivision
AddressfLacation � SeclPtiase Lot # - - �
. ,
. Se�tic tanic � cahon es .
. St�te 1D/date�TB z� 7-$-� /'b zS T�+enct� 1Nldttt ft a,
Capa io6 9�• Trenci�. Depth �•� ,�� ` m. �_ .
Tee and Ft� � Trench Len ft.
Baflie � � Tt�ench Grade �
� Sealar�t Trenci� S acin �
� Riser ifi iicable Rodc D and Qual'
Tank Outlet:Seai � � Da�nslSte owns etc, • �
Pertnanent Marker Pressure Laterals � �
� - - Pump Tank � � Hoie S�acing . � �
� � � Oe ... . . � .. .
. � Capacity . al. � Pi e Sieeve . � - - • . � . � . - .
Waterproof /Sealarrt � Tum-u rote�ors � . . . .
�� � . Wser . � , . .Requined ge�acics . �
Watet� l i trt � � � From Wells -. � � � � � �
. . pump- � Fram Property lines � � � �. � .
� �eck ValvelGate Valve . � � .- - Structuc�es/Basemertts.:: � �.- . . .
-� i oe . . . � es rai� e, a _ . . . . .
.� �oats/Sliuiic�tes.�: . � � . • . . . . _ : . _ . SurFace`VUaters . . . _ . . . . .. . � � - • -
. Alarm visable and audlbie Pubiic Watef Sup Ges
� Eiectrirai Camponesrts Vertica! Cuts >2 ft. . �
Ra�e m Water Llnes �
Ap mved Pum Mode! Ve,h�le Traffic
Btacdc Unde�- Pum , Ad' cent� ms � � -�
Pu Removai Ro elChain Easements/Ri ht of 1Nays - -
�Distribuiion Sjrsi�m � Other•
S�eriai Distrt'bution ' Eas�metris Recorded . .
r�ess�re an' e r c�act
Law P�+essure Pi e • Tri-Partate A reemerrt
r. Pipe Material and Grade •
Valves • � .
' .Camments' .
� . pcf�d rev. 3l13/07
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� -� �C � �T1��ICR�Y
���u�-���.��.��.� ���.a�:�.
Owner: �
Locarion: �"p
Subdivision:
D�O(k�r �D � Z 4
,
C�p�� �J�-11Jf � t �LIA M �.
D�o D��llasl _ I 0- Z4 — d4
Grout Log I+
Tax Map �� Parcel # � `i
Lot #
� Well Construction
Distance From nearest Property Line (Minimum 10 feet) '
Distance frorr��,g�ic System (Mi�im�un 60 feet) •
Total Depth: ���Z ft Yield: 1�J GPM Staric Water Level: 3O ft
Water Bearing Zones: Depth �d it ft ft
Casing: '
Depth: From � to� ft. � Diameter: �� in
Type: Galvanized Steel
Weight: Thiclmess: $� Height above Ground: � 2. in /
Drive Shoe: Yes No Any problems encountered while setting casing? _Yes . No
If "yes" give reason: _ —
Grout: -
Neat: Sand/Cement ✓ Concrete GraveUCement
Annular Space Width �_ inches Water in Annu�ar Space Yes No
Method of Grout: Pumped Pressure Poured +� Depth _�, to � Q_ Ft.
Materials Used:
No. Bags Portland cement Weight of 1 Bag Pounds
If mixture (sa , gravel, cuttings) — Ratio to
ID plates: _ Yes _ No . 4 x 4 slab � Y s No
Liner: — —
Depth: ��03 Date Installed: Grout: �M Installed by: ��'C��
Drilling Log - Location DrawinQ.
I hereby certify that the above information is correct and that this well was constructed in accordance with regulations set iorth
by the Person County Healxh Depamnent. , '►
Signature of Contracto
ID�# 23 � � Date° ��`�Q �—� `t
, , Pump Installment ,
Pump Installation Contractor: State Registration Number: '�
Pump Depth: ft Static Water Level: ft
Pump Make & Model: Pump Size and Rating: , hp gpm
I hereby certify that this pump was installed and the well head completed according to the Person County Well Rules in effect
on this date and that a copy of this record has been provided to the. well owner.
Pump Installer Signature Date: PC�ID rev O1/27/04
PERSON COUNTY HEALTH DEPA�tTN1ENT
355�, SOUTH NIADISON BLVD.
RO:YBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SArti1PLEANALYSIS
Name of Owner or Tenant ���j,�-�� -��.
Address (�(.,g� ���� 4-Z Counly���„
Collected By �� �--
Date Collected 5-1�-c�� Time Collected ��-��
Source: f� Well ❑ Spring � Other
i
Location: ❑ House Tap
pNo Charge Charge
�Wel� Tap ❑ Other
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Total Coliform
FecaVE. Coli
Results
Present Absent
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