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A iication Date- �� ` Tax Map #:
Amount Paid: C . !T� � .�.�5.� � ,����.5
Receipt #• '�'� 4' f Parc$i #:
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APPUCATION FOR SEt2VIC�S
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT FALSIFIED
CNANGED OR THE SITE IS ALTERED THEAI THE IMPROVEMENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVQLID. -
1) Permit requested by: (Owner/agent/prospective owner): � s��� � �c�.tac,�<
Home Phone: ��- S�4R- Ob4 y Address: ��f �
Business Phone: > �4, -,i q 9- Cz�4 � ''
2) Name and address of currer�t owner: �- �
� �,
3) Property Description: Lot size: � t�.zX'3Township: �s�.y �xkSubdivision: Lot#
Directions to the property (Including road names and numb�ers)�. —4�P5 -iC �lasS�.t o��o� ��0 �-�., 1-
�fa��l Q(1 �Q,�' �x..j(r�9� �t V'� l►..('1c�ZrC :-xir�' i�4�11•t
4) F�roposed Use an tructure Description: answer each, pf th f Ilowing questions: � �'
a) Proposed �isting Type of Structure: j'�°!0� �''� Width: �o Depth: �`a
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) �arbage Disposal: Yes . No �
5) Water Supply Type: Private �(new or existin , Public� Community , Spring _
Are any welis on adjoining property? Yes�No _ If yes, please indicate approximate location on the
�site plan.
6) Does your property contain previously identfied jurisdictional wetlands? Yes_ No�,
PLEASE NOTE THE FOLLOWiNG:
➢ A PLAT OF THE PROPERTY OR SITE PLAN AAUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPEi2TY L1NES 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
STAF�.
I hereby make application to the Person County Health Department fo� a site evaluation for the on-site sewage disposai
system for the above-described property. I agree that the cantents of this application are true and represent the maximum
faciliiies 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
PC1iD. rev. �6127/02
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Applicani
Location:
T��x M•�� ' P�.rcel #
S'll h @�II V I�5�1011
Pla���se S�ct�ion Lot #
Improvement Permit -
Permit Valid for '� Five Years No Eapiration
Type of Facility: r. New ✓ Addition Water Supply I�,nvc�- .
# of Occupants Co�.k # of Bedrooms Projected Daily Flow 3t�p g.p.d.
Proposed Wastewater System: (�,-.,,�a,,,,�,� �
Proposed Repair: ��Nvuc,a.-�.�c ( '�S � �Q�,.� ,�...�
Type: 11 c
Type: � .
Permit Conditions: �em=.+5 c.�+�� ���• ��u� a'� ,� �e���-�. n�..s. ,,,' �^��^.,� S,k
. _ - - � • —
Owner or Legal Represen 've Si ture: � � • Date: l �� l�
Authorized State Agent: Date: �/- 8- �J
The issuance of this permit by the Health Departinent in does not guarantee the issuance of o�er permib. 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
Rule�or 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.
Autho.rization to Construct Wastewater System �Reqnired for Building Permit)
* See site plan and additional attachments (�.
Proposed Wastewater System: (�,y,�,.�,�.,,9 Type Ti� Wastewater Flow 3c�o g.p.d.
New � Repair Expansion Soil LTAR: .?� s g.p.d./ ft 2
Type of Facility: S�. �. � k� �Q4.t �., _ Basement Yes X. No
Wastewater System Requirements
Tank Size: Septic Tank: of �J gal Pump Tank: =� al � Grease Trap: -- gal
o�� c� � �a-o�
Drainfield: Total Area: � sq ft Total Length �s , ft Ma�mum Trench Depth ? 8' in
Trench Width �_ ft Minimum Soil Cover: �_ in Minimum Trench Separation: n1 ft
. � Disfidbution_Box
(p � I,�w �.�- ', `�7� �;
Authorized State Agent:
Permit Exx
The type of system permitted
the permit.
Owner/Legal Representative:
Date: /
Serial Distribution Pressure Manifold
Date: /c�����
Alternative. I acc pt the pecifications of
Date: / � �
C /30/ 02
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Name t�J� �C,Q c�. � Tag Ma.p # 3J Pa�rcel. #_�
Subdivision � Section/Lot# 3
. . �a_ S-�y
Authorize State A.gent • Date .
`� System com,�ionents r�epnsse�st appro.ximarte�con�ours only. The contrdctor mr�st, fTag t,he system�irior to
Isegr.'nning the islstallatian to insure that pmpergrrrde xs maintained ::
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WELL PERMIT �
PLEASE SEE ATTACHED PLAN FOR WELL SI�'E LAYOUT
Tax Map ,pt3� Parcel # t �I � Townslup:
Applicant: IA �04(,�,� aQocl�
Subdivision: T— Lat # �
Location: �Ici� > l- o� }-k�sell f-l�s-�w l�. -� ����►� vn C. ti►/a ..:t,
'I`ype of'Water 5upply: �Individual Community Public
Iteqniremen#s:
Sita Approved By: Cg ! � 1a-US Liner:
�Grouting Approved By: CS 1-�Z-�S ��Installed by: '
Well Log. Cg � 1-12 - o S Depth set: � �
Pump Tag: � Grouted•
Well Tag: � � Date: �
_ Air vent: . � Cs a= � s- Js
� Hose Bib: ✓ � Water Sample: �
' Casing Heigh� ✓ . .
Concrete Slab• i � �
Well Driller: �x.��asr � \ - ��� .
Well Approved by: � � Date:, Z- � 6-�
****See Attached Site Sketch**** �
Wells must be 10 feet from prope�rty lines. �
-� Wells must be 100 feet from s�ptic systems.
Wells must be at least 25 feet from any building foundation.
,
Other conditions: �11�� s��e Sti.ak�9, ,
PCHD rev O1/27I04
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Applicar� � . . .
Location: �°� S � � c�.. �-1zss.e�c �� �. � I��- �^ %. -�'/�r �►�:I� �
. . . ���GT�t101'i: �Gi'i'i11t
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� System Type (In Accordance Wiih Table Va): •
� THIS .SYSTEM HAS BE�Ai IN�TALLED � IN COMPLI'ANCE WfTH APPLlCABLE NORTH
'. � CAROL1Ni4 GENERAL STATUTES, RULES .FOF� .SEWAG���:TREATMENT ANQ �DISPOSAI.,
� AND- ALL COIVDITIONS OF THE tMPROVEMENT ' PE�tMIT .AND CONSTRUCTION
AUTHO . TIO .. . . � . . °
. . . � . .... . _ . . .i �. � a �cYS � .. � .
� � Authorized S te �Ag fi � � � . . � .. � . . . : � Date • - . . .
Installed By: �1� �n�_o_ n�'— 1- 1�'- '� � --
. . ' ' Grrle� B� - 'w�: •' . ��' .' . �.
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PCHD, rev. 07/29/02
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1���a-��,.,Y„ ��.��.Il IE-3L��.71�7� � DG��OGI �'' J �_
/ J- Well Log
Owner: ' a lOv' l�
Location:
Subdivision: Lot #
Tax Map�� L�
�
Parcel # (�
Well Construction
Distance From nearest Property Line (Minimum 10 feet) �?i
Distance from Septic System (Minimum 60 feet) /Ol�
Total Depth: ,�. v ft Yield: GPM Static Water Level: � ft
Water Bearing Zones: Depth � ft ft ft ft
Casing:
Depth: From � to —�� ft• Diameter: �
Type: Galvanized Steel .
Weight: Thickness: Height above Ground: in
Drive Shoe: Yes No Any problems encountered while setting casing? Yes
If "yes" give reason:
No
Grout:
Neat: Sand/Cement � Concrete GravellCement
Annular Space Width inches Water in Annular Space Yes No
Method of Grout: Pumped Pressure Poured 1� Depth D to -'� Ft.
Materials Used:
No. Bags Portland cement Weight of 1 Bag � Pounds
If mixture (sand, gravel, cuttings) — Ratio to
ID plate� Yes _ No 4 x 4 slab _ Yes _ No
nrilling Lo� 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 D artment.
ID # ,�%Q � Date %`� ��2' -��
Signature of Contractor pCHD rev O1/16/02
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