A30 58AQaltc-atlon Dat�: � -13 -6 3
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Tax Maa #: ���
Parcai��: � �
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�.�ermit reque�ted by: (owneelagentlprospec�ve owner):� L`�' n • f�-Wr �y! c�.
Home Phone: �'3,� -��I9-773 d Address: .S- i�J ' J2d
Business Phone• F � : C a? S�/
2) R�ame and �ddeess ai curr�nt or�mee; SGzf�! �
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3) Pra�xerty De�cripti�n: Lot sixe: � Tawnshlp: lcsh F� �"5ubdivisian: Lot # '
Dit�ec�ans to the prop�y (Induding rnacfna�tes•an umbers): o i �r d r r r r�!�!i ils
' . -flw �4 S' �a Yo wK r C' ;-�.
i.
4) P�po�d Use and Sfiructure�]�scripti�n: answ►er each�f the faU� ques�ans: �
a) Propo�ed . Exlstin9 � TYP� of Shucture: t'/'Qtat� S� Width: Depth:,_
b) Num6er of �edroams: Number af occupants or people to be� served: -
c) Basemen� Yes . No �! Wlll there 6e plumbing in #he•basemant'1
d) 6arbage Dispasal: Ye� � ,1Va C� .
S) W�ter SupPl� 'Typ�: Privabe ✓new _ or exJsiin�___)� Public� Commw�iiY�, SP�9 ' .
Are any wells on adjalning property? Yes ✓No _ If yes, pl�ase indtcate appcoxlmate lacatiari on th�
.si% pi�rt. •
�
�6j Does your propeaty contatn.previously id�nt�i�d jurtsdlationai wa�tlands? Yes No �
Pl.EA3E N[ITTE THE FOLLOWIIdG�
➢ A Pl.AT OF TWE PROPEiZT( QR 31TE PLAN RAUS'T 8E SUBMRTE� WI'ii�i TH[S AP�4.IC�►'T10N.
➢� PltOP�TY LlNES AND CORNERS NIUST 8E CtEARLY MARKE�. •,
➢ THE PROP08ED LOCATION OE ALL. STRUCTURES fl�lJST 8E 3TAkED OR FLAGGEi).
9 THE �ITE dAUST BE RE�4DIl.Y ACCE8518LE FOR AN EVALl1ATl�N BY THE HEALTH DEPARTOAEi�iT
STAFF. � � �
i hereby make appilc�tian to the Person Ccunty Heatth Department for a site ewaluatIon fior the on-site sswaga �18Pasal.
system for the above-described property. I agree that the co�ents af this application are true and represes�t the maximum.
faciii�es to be plac�d on the properly. I understand ff the site is aitered or the intended use ctlanges, ttte permit shali
become lnvatid. � •
�-l3-0.3
Cwner or Lega! Representative � Qate
Pc�o. r��. us�stla2
'Tax l�iap #�
�PPlican�
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Subdivisiori: Se�tion: Lo�
I.ocation: �
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�'v�ne of Wa�r Su��fle: v'� Individual Community Public
Re�uireffient�- .
Site Approved b
Grouting Ap oved by ' �r� �
Well Log
Well Tag
.Air Vent �
Hose Bi�b
Concrete Slab
Well Driller. �
Well 1�pproves� By: I)�te•
'�°5ee Attacflzesi Site Sketch�`
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systezns.
Wells must be at least 25 feet from anp building foundation.
Other conditions•
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�C�„���
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PC�-ID, rev. 09/07/01
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Name � ��f,��l'Q� � -� � Uv �'e+�.ire-
ized State Agent
SI'�'�. 5�'I'�I-�
Tag Map #..��.Parcel # � U
Section/Lot#
_�
Date �
System components represent approximate�contours only. The contructor must, flrcg the system prior to
beginning the irutallation to insure that propergrade is snaintained �
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s�a1e: � cM�2
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_ _ -` �--.^ -�� � �T�i"� �Y ���� �R�r� ►�i�.��u� �Lu�Dmsa� �C-
T�� n-2 -v ii �r^ �c� �i�n •�rn-n. ceA Zrn t�.�n, �l ZL"� �.tn.Il. tLTia lJ�qJIyIJ LNU�UI�J �� G.. '� D�
Owner: 1 �
Location�
Subdivision:
Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from tic Svstem (Mi�um 60 feet)
Total Depth: � ft Yield: GPM Static Water Level: � ft
Water Bearing Zones: Depth lti�a ft ft ft
Casing: n � ,
Depth: From � to `�'�� ft. Diameter: b1� in
"I'ype: Galvanized Steel �
Weight: Thickness: �� Height above Ground: in
Dri�-e Shoe: Yes No Any problems encountered while setting casing? _Yes ._ No
If "yes" give reason:
Grout:
Ne�lt: SandfCement � Concrete Gravel/Cement
Annular Space Width inches Water in Annular Space Yes No
Method of Grout: Pumped Pressure Poured ✓ Depth � to �.� Ft.
Nlaterials Used:
No. Ba�S Portland cement Weight of 1 Bag Pourlds
If mixture (say�ci, gravel, cuttings) — Ratio to
ID plates; ✓ Yes _ No �. 4 x 4 slab !� Yes _. No
Drilling Log Location Drawing
From � "1'0 � Formation
' � � s��i r
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kQi
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► 39
�i 37
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! her��hv cPsri rv rt�;u �!�e �ir.��ve �ntc�rmaunn is cQr.cect and that this well was ennstructed tn accnrdance with regulations
set �orth by the Per�c�n County �-iealth Depai-tment. • . .
, Signature of' Contructor � ID # � � � Date ' — ��'���
; � PCHD rev 09/30/O?
Applicat(on Date: `f ���b�
Amount Paid: i 0
Receipt #: �.
Tax Mao #• f't 30
Parca! #: �O
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APPLICATION FOR SERVICES
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT 1S INCORRECT FALSIFiED
CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMR AfVD AIJTHORIZ,4TION TO
CONSTRUCT SHALL BECOME INVALID. � � �
1) Permit requested by: (Owner/a ent/prospective owner):
Home Phone: - - �j' Address:
Business Phone: f$ � ( 2 �f
2) Name and address of cunent owne�: rt n k� � � i,1 —� i' �7-a� "
� !?I Y�(�'�-�.Y �CI �
!�u rcl t� � 1 l s� N C a7 S�( �
3) Property Description: Lot size: �_ Township: �
Directions to the prope�y (Including road names and num
I f � �.r i. � T � n i
#
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✓
4) P'roposed Use and Structure Description: answer each of the foliowing qu�est�'� M
a) Proposed�, Existing T p o# Strucfure: J�a��er �:.•;t-� � G�` �N, idth: ZO Depth: �i5
b) Number �f Bedrooms: ��tnber of occupants or people to be s'grv o��
c) Basement: Yes , N� Will th re be plumbing in the basement? N f�
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 ident�ed jurisdictional wetlands? Yes_ No�
PLEASE NOTE THE FaLLOWING:
➢ A PLe4T OF THE PROPERTY QR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATIOM.
➢ PROP�RTY LINES AND CORNERS MUST BE CLEARLY MARKED,.
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAFCED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMEWT
STAFF.
I hereby make appiication to the Person County Health Department for a site evaluation for the on-site sewage disposal
system for the aboJe-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
or Legal Representative
(
�
Date
PCHD, rev. 06I27/02
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� 31.�7�'�3L "� O 3L'31_"n'�rT � �g_ � �L. � � � �� � ��
'I'ax Map # �� Parcel # S� �
�xisting Sewage System Report For. Mobile Home Replacement a��'� y�,
� Addition Type: bQc.' °� �.
Requester. �rcn�`� � h ` Y� Home Phone# 33(�-SS�', - l�3 .
q$� ��',-,Zflx� �.z Business # 91q - 7"3a-a�5�
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Original l'ermit Located: ►'�� Water Supply: ���v�
Septic System Designed For: '/Residential Business Other
# Bedrooms�_ # Employees Other
System Type:�o��� Tank Size: ��c'�o Nitrification Line: 1$O� x 3�
Aate Installed: ? Certified Operator Required: �
�n-site wastewater disposal system shows no visual signs of malfunction on$� Z' a5
Permission is granted to: %�l.i� � �!�2��t9.Y� �
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Environmental �-Iealth Specialis Date: �- Z� v5
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�Y2'11�i�L �1C.:t ��,n �
LDcation: Ll�i �-� L �.., C� -� ��-tv k.W 2� �
's , LA.. � rr.. � C� �. �1 .
. � �apro���t Pea�� , . �
Fe�t �Talid fmr � �'+ive
'I�ype of Fac�ifi�: `' '
# of Occupants
Proposed Wastewater S� .
Proposed Repair: �
Peanit Con�ition
Ye�a�. l�iq� �p�rada�n �
� r��� New A.ddition ZC i��ter �uAP�'��_�� _
# af Bedro ��� jected Dat`ly Flow g-P•d. � .
�5#em: ��,� � � � Type: �
• • . 'l�mra•
. . ' D�• � -- y_ os
Qwner or Legal Re�res e Si �
Authorized State Agent: . � . Date• s- z-�s
TiLo issnanco nf tfiia peimit hy tho Hesith Daparlment in does nn guaraateo the isananca of other peaniia Yt is t�e respons��liiy of the
aPP�P�P�Y owncr to in sarc that aIl Peison Cow�iy pla�mg and' Zoning and Bwlding Iuspections requiremeats are met. 'T}ais
Im�prove�►ent P.er�ult is su�3ect to revocation ii the pite i�lan, Plat or the nttended iase eiianges. The Improve�ent fl'ermit is not a�fected
b� a'change ffi ovnmerahip oi the propertg. TLis� permrt was issu� m complianc� wlth tLe jprovisions of the N�a�th C�rol�a `Luw��d
,�a for Se�w�e T�eutrneatt and Disaasul 3`vstera�.s' (15A NC,r�C.18A .1900). Neither Person C�anty nor the Environmental �ealtla
Special'sst x�arran.ts that tlae septec tmnlc system w�7I c�mmtmue to fimctioa satisiaetor�fly m t�e futare or that the �wa�ter snPP�9 � remain
patable. � " � .
�A.n�ao�azataon � ���tan�'�as��ater� S�steaai ��n°� ��a �� �e�it) .
* See site plan and addittonal attaehments (��. � �
Proposed WasteWatex Sy�:��.n��� �.-��- 'I�jpe �_ Wastewater Flow N8� . g.p.d
New R.epair Fapansion �. S� �'�� g.p.�. $ 2
Type of Facility:. F � s�h� _ � � � �Basement �Yes �No
��st�water Syste� Ytequireffients � �
Sia�: Septic'��: ; g�i , . �amp �anlc -- � gal' . Gssase Trap: '' S�al
?x` ��' c�.a-,�. d� - , .
field: 'Total Area: — sq $'Tot�l I�ength ZSa ft �una'��ene� �3ep#�a 2�( an
c$d W�th 3 � �mil Eover: ��_ � Minimum'1'renc3i �eparation: �_ $
� I)istri`bution Box Secial Disfnbution �Pressure Mam�old
c.�Z o x:�
�4�aoa�ed State �ige�t: �
� Permit EXp' on I�ate• 5- 2-
Date: S-z��s
The type of system pe�nitted is � Conventionai Innov 've Alter�ative. I ac��pt the specifications of
the permit ' � �
+IDvvnerl��g�1 ��a�e���: ��,,� . . . Dats: P �' - v ,
. . � �C�7/30/2002
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it -..�.�Il3'�trn �rm-n,g7CS1�.ffi.!L �L �L�L:'�..11�JK1.
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N�ame F-,-� lU� �1..,
Subdivision � � �
Authorize Stat nt ��;,r,�� ��
Systerea cornpanes�s s�res�nt a��ro
begraaning the installair.�n to insure
SC1�e: ' „ - �,
�aX �/�.� ��_P3TC2� ��_
Section/Lot#
� �_��S
Date
vnl,y. Tiae contractna� snus� fdag i3ae syste�a psz�r im
'e is �rsaintained .
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I'G�, ��. 09/12/�1
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A�plican�
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a � �aoa �
���1i�Jl�'u' 1�JuliYL'�'�115 fei
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= ,. -
System Type (in Acr.ardar�cz With Tabie Va): �
TH1S SYSTEIV! HAS BE�� 11�S�'�LE� 1�9 COt�IPl�1VG� WtT}i APPLlCABLE AlOF2TH'
CAROLd�, GEi�EFtAL STA;�'[JT��, RIiL�S �t7R SE3tIlAG� T�i�9itEiVT AND DISPOSAL.,
AND i�LL �ONDI�'it�iVS OF ' THE iiVIPfZOVE3VIEiVT PEi�A1T AND CDi�STRUGTiaf�
� �llTi-tORlZAT1�N. � '
r � .� Io—OG. - ..
P+uthorized State Agerrt � Date �
I nstal(e�i By: �- CaI� L � Date: S- 9—D �o ..
�. � Poin�e,��r R�' . . .
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rCHC, r�v. G7/2�/G�
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Jt��� ��f`�� �9��a��'���.� '��;���� � ��� �� � g �
Tax �tiap � f-�36 Parca� # �ys�ern Ty�� (ia�le �!a) .
Owr�erl?��p[icant� � S�bdivision
AddresslLncation Ser,�Phase Lot � �
Se��c 3'��ak �na��ilD�� �i� c��aon n� �ai�a a� �.
� Staie�IDldate �x�`s�i'n � Tre�ctt �dfh � . 3 � ft. ,/ S -9_ .
Ca aci a�v o �� � Tr�nd� De � th �� in. +/'
Te� and Fiiter T.tettctt Len 28Sft. ✓
� Baffl� Trencf� G�ade . . .
Sealan# Tr.enct� S ac9n
� � Rise� ifi a ia�able � � Rodc De th and� Quai'
• �'ank �udef Sea! DamslSt downs e#c.
Permanent Mar�er - Pressure Lat�rais � � � �
. Puenp T'ank � Hoie Spac�ng � � ..
� State a e o e ize �
... Ca ac' � ai. � Pi e. Sle�ve
� � Wat� roofi /Sealant Tu slProtecior� �
Riser � �dequires!' Seffia��.
Water Ti ht � From� Wells � �� � � S- -a4
y � Pu�ap Ft�om Property iines .
. �hecic Valve/Gat� Valve Structures/Bas��netrts
�� Anti-s� on o e rt es raina e� a �
Fioats/SwFtcf�es � � SurFace Waters
.Alarm visaioie and audibie Public Water Su lies . •
Electricai Com onents • - Verticai Cu#s >� ft. �
� Ra#e m � Water lines . ,/ �
r+ove� Pum i�lode! Ve�icle�Trafric � �
Blocic Under Pum Ad'ac�n# �ms
�� l'um Removal Ro elChain • ��sernefrislRi hf.of Wa
. � �is�ibutao�_ Sy��ara tt3ilaer � �
• Seriai Disin�ution � . Eas�ttet� Recarde�
� ressur� an o �rtm era or ntract �
�ow Pressure P� e �ri-�artate A re�ment �
�4 r. Pi e Iwi�terial and G�~ade - � �
� �at�r�s
, C�me�ten� . . .
.�
�ct�d re��. 3/1�101