A30 146� � � s�'�� -��� � o
A iication Date- �'� l � A� Tax Map #• "
Amount Paid: C • �I'� � !�
RecEipt #: '�'� 4' � ,�1 �
r� � 0�� ParcEl #•
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APPLlCATION FOR SERVICES
IF THE INFORMATION IN THE APPUCATION FOR AN IMPROVEMENT PERMIT IS INCORRECT FALSIFIED
CHAFVGED OR THE SITE IS ALTERED THEN THE IMPROVEiIAENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME iNVALID. -
1) Permit requested by: (Owner/agentlprospective owner): � sl� � �c`�.`oc,�C
Home Phone: ��- S"9�- d�� y Address: � Y G
Business Phone: j 3�i- .i � 9- c�G4 �' ''�
2) Name and address of current ownec �'� � � ,_
nr ��
3) Property Description: Lot size: �i�.�'3Township: �-s� �rkSubdivisian: Lot#
Directions to the property (Including road names and numbers): 4'�S -IC �lo.ss�.l o�-'b� ��4 �+�n 1-
��i., on le.�# �.s��� At � t t,,.ndiT�ro.:...,�5 en.l�is
4) proposed Use an tructure Description: answer eachpf th�! f Ilowing questions: � �'
a) Proposed Existing � Type of 5tructure: �i��G� �''� Width: �� Depth: ��
b) Number of Bedrooms: '3 Number of occupants or people to be served: ,
c) Basement: Yes , No � Will there be plumbing in the basement?
d) 6arbage Disposal: Yes , No �
5) Water Supply Type: Private �(new _ or existing , Public� Community� , Spring _
Are any wells on adjoining property? Yes�o _ If yes, please indicate approximate location on the
�site plan.
6) Does your property contain previously identified jurisdictional wetlands? Yes_ No,�,
PLEASE NOTE THE FOLLOWfNG:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH TH1S APPLICATION.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED�= ,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAFCED OR FIAGGED.
➢ 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-siie 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
� ���
Date
PCHD, rev. 06/27/02
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Applicant:
Location:
T��x M���� � � P�rcel # � •
S�u k� ei'i v i�s�i o n
Ph���se�Sect�ioia Lot #
,r % r,,, 7�
Improvement Permit
Permit V�lid for '�Five Years No Ezpiration
Type of Facility: �;,o,� �c�.:��, �„� New �` Addition Water 5uppiy I�n�.ie .
# of Occupants ��...�.? # of Bedrooms Projected Daily Flow 3� g.p.d. � �
Proposed Wastewater System: .�� � �-���uG.�l�. 3•a1�-oS . Type: ��_
Proposed Repair: '�'��.a��o C��s i�Qa,,,,,,,,�,_l Type: � .
Pennit Conditions:
Owner or Legal Represe
Authorized State Agent:
Date: �
Date: �%
The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibiliiy of the
applicandproperty 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 ownerslup of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rules ,�or Sewa�e 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 w�l remain
potable.
Authorization to Construct Wastewater. System �Required for Building Permit)
* See site plan and additional attachments (�.
Proposed Wastewater System: l '���"�..+�.�,�v �mouc.�-►�t�.
New ✓ R air Expansion
Type of Facility: � l,� ��-• �=
�
Type Wastewater Flow 3�.p.d.
Soil LTAR• .��S g.p.d./ ft 2
Basement _ Yes >C No
Wastewater System Requirements , ,�
Tank Size: Septic Tank: �� gal Pump Tank: -" �� Grease Trap: �— gal
Drainfield: Tota1 Area: I304 sq ft Total Length �� azimum Trench Depth 1�-� in
Trench Width �J ft Minimum Soil Cover: �_ in Mi.nimum Trench Sepazation: Q ft
Distribution: X Distdbution Box
�S ecifications: �YQ - C�ns �,b �
���� ',�ns�r.�(?l �,�.,�� w�k- C�
Authorized State Agent:
Permit Expiration Date:
Serial Distribution
�
Pressure Manifold
Date: 2$/ -0,�
The type of system permitted is Co entional ovative Alternative. I cept the specifications of
the permit. �J�
O e/L al R esentafive• Date• G
wn r eg epr
- PCHD7/30/2002
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Date .
�� sy� �o�ro� ��s�t �pro���coninars only. The contrdctor »urstjsiag the syst`em�riar to
Iregirzr�ing the irrstaAat�ion to irrsrsre that propergrade rs rnaintained °:
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WELL PERMIT � .
PLIEAS� SEE A7'TACHED PLAN FOR WELL SI� Y�AYOYJT
,. .
Tax Map �'� Parcel # � u o Tovvnship:
Applicant: In�esl�; �Ic.�oc��
Subdivisio � Lot # o? � �
Location• W�`, F, 7 (� �., -i�.�.l l ��-�. � � ��_
� 'I�. �M,�Q . �
1`ype of Water 5upply: �Individual _ Community Public
�keqnirements:
Site Approved By: .S S `� o'
Grouting Approved By: .S 5 6 0'
Well Log. ,, S �(/S/o5'
Pump Tag: ✓ � `� .
Well Tag: v '
� VeDt' �/ � <-! - 7vro5
Hose Bib: ✓� �
Casing FIeigh�`� �
Concrete Slab: . . �
Liner:
Tnstalled by: �
Depth set: � �
Grouted:
Date: •
Water Sample:
Well Driller: q r v��� ,
Well Approved by: Date:, �I • ac�-- os
****See Attached Site Sketch**** �
Wells must be 10 feet from property linea.
� Wells must be 100 feet from e�ptic syatems.
Wells must be at least 25 feet from any building foundation.
Other conditions: �� � � W �1 �. ��z� .
PCHD rev 01/27/04
i ��� � �� � � ,� �� �� Tax M�p �I Parcel # ��'
�'� � Su,bcilivision
�.� i \ • i � ' Ph��se. Sect,i�on Lot # •
� l 1
11 _ , , � � .. ,�� , ,.� . ��� � I I I ,- .�, i � I , # of Bed,rooms
Applicant: v� ,PS..+ ��G�— -
Location:
� � �
-;� `:.:. �_ - _: :I , ' �..��� r i
System Type (in Accordance With Table Va): 11 '
THIS SYSTEM HAS BEEfV INSTALLED 1N COMPLIAIVCE WITH APPLICABLE NORTH
GAROLINA GEMERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMEiVT PERMIT AND CO�ISTRUCT�ON
AUTHOR(ZAT10N.
Authorized tate gent
Installed By: .� �- /�
� �' bs�
Qaie
Date: �
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CHD, rev. 07/2I
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��P-r�c �- �c� a�sP����o��c����cL��a (�'vne i' - �v�
Tax Map # o o Parce! #/ Sysiem Type (Table Va)
Owner/Applicant Subdivision
Address/Location a�� SecfPhase Lot #
� Septic Yank nitia aie itn cataon �nes nitia ate
State 1D/date�� ' 7�; o � Trench �dth 3 ft, `� �f
Ca aci ado ai. � Trench De th /��T� in.
Tee a.nd Fiiter T,rench Len th ft.
Baffle Trench Grade � �
Sealant Trench S acin
Riser if a licabie � Rock De th and Quali
Tank Outlet Seal Dams/Ste downs etc.
Permanent Marker Pressure Laterais � �
Puma Tank Hole Spacinq .
� Ca acit
Water roof /Seaiant
Riser
Water Ti ht
Pump
Check Valve/Gate Valve
and audibie
� Rate m
A �roved Pum � Mode!
Blocfc Under Pum
Pum Removal Ro e/Chain
��Distribution. System
� Serial Distribution
ressure ani o
Low Pressure Pi e
A r. Pi e Material and Grade
Valves
Fipe. Sleeve
Tum-ups/Protectors.
Required� Setbacks
From Wells
From Propertv lines �
Surface Waters
Pubiic Water Suppl
Vertical Cuts (>2 ft.
Water Lines
Vehicle �Traffic
Easements/Right.of V
Other
Easements Recorded
e e perator oi
Tri-Partaie AQreemen
Corramenis
pc�d rev. 3/13/01
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IE��n����.,�. ��.��:]l IHL��.Il.�.I�.
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Drille.r ID # � _
Com����ny N�me s_ ' ' � �
D�t�e Drilled •
I Grout Log
Owner: E'Sl C�L Tax Map 3� Parcel # l��
Location: �
Subdivision: s ,� Lot #
Well Constrnction
Distance From nearest Property Line (Minimum 10 feet) �!�
Distance from Septic System (Minimum 60 feet) ��
Total Depth: � ft Yield: a� GPM Static Water Level: ,� � ft
Water Bearing Zones: Depth � ft/� �/ ft/�' !i ft ft
Casing:
Depth: From � to �� ft. Diameter: � in
Type: Galvanized Steel
Weight: Thiclrness: �� Height above Ground: � in
Drive Shoe: .�Yes No Any problems encountered while setting casing3 Yes �o
If "yes" give reason:
Gront: �
Neat: Sand/Cement Concrete GraveUCement �
. Annular Space Width inches Water in Annular Space Yes No
Method of Grout: Pumped Pressure Poured / Depth _�_ to � F�
Materials Used:
No. Bags Portland cement Weight of 1 Bag Pounds
If mixture (sand, gravel, cuttings) — Rario to
ID plates:�Yes _ No 4 x 4 slab ! Yes _ No
Liner:
Depth:
Date Installed:
Drilling Log
Grout: Installed by:
Location Drawing
From To Formation
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I hereby certify that the above information is correct and that this well was constructed in accordance with regulations set forth
by the Person County Health Department. n� �
Signature of Con c or ,
� ID # a�i4� Date •� �� �d��
Pump Installment
Pump Installation Co tractor: �=Q � State Registration Number: ��o ��/
Pump Depth: �� ft tatic ater Level: c� S ft
Ptunp Make 8L Molel: J e�Q�„�' � Pump Size and Rating: t a hp �Q 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 pro 'ded to the well owner. .
Pump Installer Signa e Go Q�`''� Date: �' �i"65' PCHD rev O1�i27/04