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A30 30Application Date: — �� Amount Paid: .00 Receipt #: �-� ���4 Aa�� ��5 •�� 2 C�` �.a �,150 ��' ��`''a' ,���,5� I��I�.��� - - -L ������ �a�ra�oa�a�+-'--^ .Daa�.m.� ��o�.���a APP�ICATION FOR SEi2VIC�5 iax MaQ #: � 3 � Parcal #: 3 � IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED, CHAiVGED OR THE SITE IS ALTERED THEIN THE IMPROVEMENT PERMIT AWD AUTHORIZ4TION TO CONSTRUCT SHALL BECOME INVALID. � . 1) Permit requested b•(Owner/`ge prospective owner): � Home Phone: - �v 3 Address: Business Phone: �-�ec�—. • 2) Name and address of current owner. 3) Property Description: Lot size: 3���T�Township: � Directions to the proper,tv (Including rpacl,�am�s �2d nu Lot # 4) proposed Us and Structure Description: answer each f� following questions: a) Proposed �,,, Existing Type of Strucfure: ����, Width: 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) 6arbage Disposal: Yes , No � 5) Water Supply Type: Private (new _ or existing , PublicJ CommunityJ Spring _ Are any wells on a joining 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 PROPE�2TY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY L1NES AiVD CORNERS MUST BE CLEARLY MARKED. , ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAf(ED OR FLAGG�D. ➢ THE SITE MUST BE READILY ACCESSIBL� FOR AN EVALUATION BY THE HEALTH DEPARTMEiVT 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 invaN�. � Owner or Legal Representative .' �^O� Date PCHD, rev. 06127l02 ZOOZ/O£ILQ�i�d . � ^ Q I � ;a�.�asa.ada� g��arg/iaw�.� :�Q . . . � , ��ad aq� �o suo�e��ads a� �da� I•atit��¢ta�� aer.}�nomzj �uoi�uanuo� �Z si pa�}tnuad Bta�stSs �o aci� a�,L .� -.$ / -C)/ -a�Q �, � PI��� ��Td� �s- :a:�Q IIo�z[dx� �.�aa �� -��a� ��S �����'' �' • va� c��cs -�'�s:p -1eu � :�o�}g��adS ��q.�Q T�?�S zog �ot�rtq,u�Q -�C :�°gp�►qg�s�Q � �- :IIo�da� ��L ���I � —� :�aao� I��S �� � � ��F� � � � �R�aQ ���1. � � O h h ��'I i�'1o� � � bo�1 ��' l�°Z �PI��' lB� - :drsy asea� •� � .: :�aBa, d�d � i� cx�� �Z �dag :azig s��awattnbag �aa�s�S �a���� aK �c sa�� �u�auxaseg. . . `: \� , :�C}�3�o od�,i, Z� 1'P'd'$ S.�-� � �1'.'I ��S IIoisaB ��da� � s� IZ .P.d. . O� �ot3 �g��11Y� -�ac�I, ��ynrt�o-1 :taa�s S � ���Lfb, Pa °�d . 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'.y:•'';:..••;�f,;:::,:..�..,:.;.,,,,::r+. .:•:;....:,.. � : ..: .��� . ... .......:..: . • ' : - . . ..: :. . :...: .... .. . �: •:.. . ... � . . . . � . .:.: �. �. .. � •.: •]k'a:19'73t]L�QD�7rn'���-man�: . •.'j�•. 7�� :...::...:.::.:. .. • ....:........:...:�:.- :�^,,.. ��'fIE`.,.�,.,�.,,�!�-'..;' �,,.'.:>. �, �;�3's8L1L��� ": � +,�j � V i �I:�Y.r�d� ���.`l1YllY g . . JC�7..r�L''Ji3YJ ��� t9Jl 8t3��1Y �.'L�t�l`1 Y'�JL� Y7'S'�IL.r� �89.:[:U 11JJ133 ��J Y Tax Map �30 Parcel #�c� Township: Applicant: �Arn CY�[� Q �� i ��p t�srv Subdivision. Lot # ( � -_� . �ici,,,.. Location: �9� � Qr n �- Z r►,.tps -a `�yp� of �ater Suppi�: ✓ Individual � Community Public �.te�quire�nen�: � Site Approved By: T Grouting Approved By: o� Well Log: Pump Tag: � 2s o Weil Tag: � Air Vent: Hase Bib: ? ;S Z�7 Casing Height: � Concrete S1ab: � ' � Well Driller: _� ,p,..��_.� Well Approvec� by: j�� �� ����. ��**�ee ��,#ached �iie S��tch*�*y Liner: 'Installed by: Depth set; _ Grouted: Dafe: Water Sample: Wells must be 10 feet from property lines. � Wells must be 100 feet from se}�tic systems. Wells must be at least ZS feet from any building foundation. . �ther conditions: Date:, .� Zs o z PC�-ID rev O1127104 ��� Y �� � � �� i_�' � ���� . . `�—� � S ,� _ � - . . _ . �--; ,-�.- � � ��� ��T ����7'�.3��7L"�.."'i3L�..4�`33�L1 1L JL��'2.�1G�C� � nl}( �{ a a �7CC �i U!Cl El I V'f Gll Q Gi - � ���c-��Lic]�iT` . rr O`! 2 f� f Q O;R1 S �i � 1 •• _ _ C,i� l • L� � - 1 • � � .�in � i - • � � 17 �c .w � � C � ��� �. . . � . . . � ' ���� � �. �� .. . : . , • . � System Type (ln Acxordanc� W�h Tabie Va�: ,�"T�a � T�its SYS'fF_�tI . i-��S �'3E� lAlST.AL.i.Ei3 ' iD! Ct�AidPL1AIVC� V109TH AP.4�i.1�ABl.E NC)I�iTPf .. G�►ROUP�3�. ������A.�. STAiUTE�, RUL.ES F�3R S�l�►G� TREATDitEi�IT AND DISP�SAL; Al�D /�1;L � Cal�lDCTt�MS � C�F ' Ti�J� �dP4ifll�ItE3�'i' P��f11T Al�i� Ct)tMSTRilGT1O1� • �U'(",r�0 �'i7t�i�[. . • , . . - ��lc�� b� ' _ • Authorized State Agerrt � • Date � !ns#a�led By: -T. C�a ��.z � � . ' Dat�• �- � � o� 0'-7 , . ^ ��� �" _• . .�q� C� • . � � ;� • ' ✓ ' I�. �-----. ,i _ 1'�� � .� �,y� i od� � . ( 3 � . . � �`` ,�'� � op, l3 � ,�o� � z o. � ! IZ �.o u . ju� ' 12Q �, _ �1 �j O� �.N �FT c.o}�vc N-r�.o� 1., I�UT 'i'o SCftI..E ���-;� r=;� r, � �^ =m� . . . ��� ��''�� ������� ����� ��� �� _ �'� T� 1Vl�p � � Pa�i # � � � Sys�n Typ� (Ta�le V�� - ►TA � Qv�me����iic�# _�� rv C� �,�Z ti Subcfivis�on � Add�e���afion SesyPf�� _ � � �o � Y� �w �i-n.� C.�� � . • • - , �. . 5 . .. TI��"�A'� 1'd7/ f��T�1f 1� ���. sf ���.� �� - � � ���� IE��uy-��.����:�.11 IE�L��.Il�I�. Owner: � �C,iv� ,? � Locarion: � l�S � Subdivision: Driller ID # •� Com�any N�me� � � 1 Date Drilleci Grout Log Tax Map�'� Parcel # � Lot # Well Construction Distance From nearest Properry Line (Minimum 10 feet) ' Distance fror�S�j�c System (Minimum 60 feet) � Total Depth: 4(� ft Yield: O GPM Static Water Level; 3� ft Water Bearing Zones: Depth � O ft ft�t r^✓ ft ( 0 ft Casing: ' Depth: From i5 to`/,_ 6� ft. ' Diameter: 6�y in Type: Galvanized Steel Weight: Thiclrness: �ge Height above Ground: �2, in Drive Shoe: Yes No Any problems ericountered 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 Ft. 1�laterials Used: No. Bags Portland cement Weight of 1 Bag Pounds If p xture (sa , gravel, cuttings) — Ratio to— —�� ID lates: ^ Yes No 4 x 4 slab �Yes Liner: Depth: Date Installed: Grout: Installed by: _ Drilling Log From Ta Formation � Location Drawing I hereby certify that the above information is correct and that this well was constructed in accordance with regulations set forth by the Person Counry Health Departm�nt. �� . Signature of Contractor ID,# ���� Dat�'" � Pump Installation Con�-actor: Pump Depth: Pump Make & Model: Pump Installment Static Water Level: State Registration Number: ft 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 S 1 � o� t-( �s��c�e.cQ, c��l I o�- �1=► c- '� n�+�.l,l,e�-r+�� � I c� ��an1 ��P� `„ o� .e.�-� s-� n e� �-�- � � ��s �c.� �� � 3 Iz oI o ri . CA►.�'CCL�t���' p o�' �4; n�. � ; ��nq�n ''� `-�'� wlil C�n�-��' �� � n w�2� �-1� bR-` "� �� �,� -�1.us1n c�� co�'�cJ`�-� �'cS2.. -To C.9-� ( � -�e�' � c�e.11 -i� n�D � •� .— �S��S�o � S� �-d . � , /�+�"