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A30 95� � Apptication Datec � �-03 Arr►ount Paid: � �ecei�t #• .� 73 7l3 ��r � �,� i� b� �,� � �. a� � ,� � �`'Yµ� ,� 3 � �d � �� °° � -�0�64� ���: � ���� �� -L c� � �1�'1L� �Y ��.�aa-.ma�_a-M�.aa-a_�a..I1 ��L�mIL�Iia APPLICATION FOR SERVICES Tax Mat� #: Par^el #: � � � COfVSTiaUCT SH�►LL BECOME INVALID. 1) Pecmit requested by: (Owner/ageni/prospective owner): Home Phone: 5'�t9 -`i tj Zo Address: � Business Phone: q ��i -3 �� - (�bu . t�� r �o t .l 1 e. 2) Name and address of.current owner: S�+Y»e.- p c Abn�� �� ` � µ� b\ e. u�d -�D ��- 1 T �O , 3) Properly Description: Lot size: i,SO Township: i=o-1c Subdivision: Lot # Directions to the property (Including road names and numbers): ;S"oo' PPS-i� �-�As:�� µ�-�� 2c' . � Ne,�l+ -+-o C�Coro► �u+�la�('���v 1� ,'Zc�. 4) ProposesD Use and Structure Description: answer each of the following questions: a) Proposed ✓. Existing _, Type of Structure:�o�i,/�r :� — s�•�iG" �dth: G�� � 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) Garbage Disposal: Yes J No ✓ 5) lfVater Suppiy Type: Private ✓(new _ or existing�, Public . Community , Spring _ _ Are any welis on adjoining property? Yes�/ No _ If yes, please indicate approximate focation on the site plan. . 6) Does your property contain previously identified jurisrlictional wetlands? Yes_ ido � PLE�►SE NOTE THE FOLLOWIWG: ➢ A PLAT OF THE PROPERTY OR SiTE PLAN II�UST BE SUBMITTED WlTH THIS APPLIC�.T10[d. ➢ PROPERTY LlPIES AMD CORNERS MUST BE CLEARLY MARKED. r 9 YHE PROPOSED LOCATION OF ALL STRUCTURES MUST BE ST�1aCED OR FLAGGED, ➢'�HE SITE MUST �E READILY ACCESSIBLE FOR AN EVALU�►TION BY THE HEO�LTH DEPARTMEPIT STAFF. f hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for. the above-describeci 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. or Legal Representative � -�3 -0 3 Date PCHD, rev. 06/27/02 ���.s� ���.��� �__._. � ,_'^ � � � � � � 7����.a-��� ��.��.]L I����.II�IL�. Applicant: T�x M�.� � � P�rcel # S�u�heiivi5.ion 'Ph�►�s•e'S�ct+ion Lot # Permit Valid for � Five Yf Type of Facility: �B # of Occupants QK # o Proposed Wastewater System: Proposed Repair: i Permit Conditions: Owner or Legal Represe� Authorized State Agent: � Improvement Permit � No Ezpiration r' re� / �� • New �Addition Water Supply W � Projected Daily Flow 3�iD g.p.d. � Type: c� Type: Date: � Z =� ��d� Date: ' � � The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the applicanbproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements aze 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 Rules for 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. �Authorization to Construet Wastewater System �Required for Building Permit) * See site plan and additional attachments (�. Proposed Wastewater System: �Dt/1�V Ql/�j`�c� � Type�� Wastewater Flow ?J�0(� g.p.d. New � Repair Expansion Soil LTAR: • O g.p.d./ ft 2 Type of Facility: ��� �r � Basement _ Yes � No Wastewater System Requirements Tank Size: Septic Tank: � gal Pump Tank: gal Grease Trap: gal Drainfield: Total Area: �2C9� sq ft Total Length �'�0 ft Maximum Trench Depth �'�'���in Trench Width � ft Minimum Soil Cover: �_ in Minimum Trench Separation: �_ ft Q•C:. Specifications: Distribution Box r Authorized State Agent: �(,/� Pemut Expiration Date: i` Serial Distribution Pressure Manifold Date: C�`a3 The type of system pernutted is � Conventional Innovative Alternative. I accept the specifications of the permit. � y� � Q� , Owner/Legal Representative: �U`)��/C- ii.cr����� Date: � L 3— �O °3 P HD7/30/2002 »,► l,.x � �J .� . ?��� � � v ...� . � � .� ^ ,� ..` �f � �� " � �� . (t�'� ��� � �� � � �f` � A � � �' V� . • �� , � � ��"V . � a • . . � Cl�r� . � � W �{ �����(a��� �./"' � ��- � . � . �� V . . %.. � � � �..1� �` �' « �,,�; �-� a � �� � to �,,QQ S�S� � V"��-� �.5��� So� � 2� t� . Q�� � �o�S� ��e- l �� . . . \� (7 C Z i � �.� � � ��� �•': �-'�j� -- �'15` � ' . � :' `: - .��,.,.I:.f �� � • � . • y � .. .•:,' ,�� l!' 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S�^±'� �.�0�1-�' ��� #: }�3 � ��# � � ��� . ��� Snbdivi�n: 5�n: Y.m� � � .�,� ._ -� : �`� .� ,� - : r ,s : -, � � � , •� . t n •s • � � t. :.: -. -�,,:-:,;ti Site .A.pptOveC� by . �� � Gmuting ved bp ll � � � We11 Log WeIl T Air Vent � Hose Bib 1/" Concrete Slab _ �-� - �� � . �, � . _ �,. . . � :.�� .� , .. �.�/ � • �; : , . , , � . �-� :- i°: _ . . : . , - . :. , ��i - - .: «:. �,, ,, - Wells must be 10 feet from property I�es. WeILs must be 100 f�et from septic systeemss• . WeiLs must be at least 25 feet from auy bu7ding foundatian, Other conditions: �� (,� �► ,, e/� Yl����.( �x � ►�S� °��Z� i,�r 9�� � � -�`%t� � /�—! ��� PC�ID, rev. 09/07/Q1 � ���. �f ���� �� Dc�Ofk�r OD � Z304. � „ , `.�`` � � �"1�"��Y c��� a� �w�J (ut�,iAm�u�k. �����-��.�.����.n. ���.���. D�o D�DOc�) _I A- Z.$- d y Owner: �� � Locarion� Subdivision: W Grout Log Tax Map �� Parcel # � 5 Lot # � Well Construction Distance From nearest Property Line (Minimum 10 feet) � Distance from Se tic System (Mini um 60 feet) • Total Depth: � ft Yield: �'J GPM Staric Water Level: � ft Water Bearing Zones: Depth � ZS ft rsta ft � 15 ft' ft Casing: ' Depth: From �_ to � Z -- ft..' Diameter: � in Type: Galvanized Steel t/ ��'eight: Tniclmess: i�� Heignt above Ground: «. in Drive Shoe: Yes No Any problems encountered while setting casing? ^Yes .�No If "yes" give reason: Grout: � Neat: � Sand/Cement +� Concrete GravellCement Annular Space Width mches Water in Annu Space 1� Yes No Method of Grout: Pumped Pressure Poured � Depth C� to L� 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: �"' SZ Date Installed: Grout: ��l 'r' Installed by:�S�jQ1DCTV�. Drilling Log Location Drawing From To Formation K Q� � Q S !/ 37 �, , I�w► . 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 Heal^ Department_ � �► Signature of Contractor Pump Installation Contractor: Pump Depth: Pump Make & Model: ID�# �3�� Date° ��'����� , Pump Installment Static Water Level: State Registration Number: � � ft Pump Size and Raring: , hp gpm I hereby certify that this puznp 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: PCHD rev O1/27/04 ���' ; , .) f ���� �� `�-.. � � � � � 1 V J.L � ��rnv�-n�-��n.s.�xn.��rn.�.mIl. ��c�.tn.��� Appiicant: Location: Tax M�p i�I P�rcel # � Su�bclivision Ph�s�e Section Lot # # of Bed�rooms �Operation Permi� , 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 AUTHORIZATION. : r�_u_o� Authorize Sta e Ag Date Installed By: ���r,v �S Date: id - 7�5' o� �-G-o� `�-�- �ooa �'�g � `1'�-. �� � � �J� , Z� �,5���. , 'J��r�pW/��✓- 7 PCHD, rev. 07/29/04 S��TiC i'�4 �C 6NS8�9E�ON C�4E��Ci.IS'�' �T'yp� lI -� S' ' Tax 1�aQ-# �� Par��! # � Systesn Type (Tabie Va) , OwnedAQQiicant Subdivisio� AddresslLocation � SeclPl�ase _ Lo�k # � � . � • . Se�tic Zan� n cation nes reri� . . St�te 1D/date� � 7' �a T�enci� Width � ft. Capa Qoo. gai. Trenc�. Depth /. fn. �. . Tee and F�ief � Trench Len ft Baffle � � Tcench Grade � Seaiant Trenct� S aai� • � Riser i� ap iicable Rodc D and Quai' Tank Ou�et:Seal � � Da�rts/Ste owns etc. � � Permanent Marker Pressw�s Laterals � � � � - - - Pump Tank � Hole S�aang . . . e � � Oe ... . . • . . . Ca aty . al. � ' Pt e Sieeve � � - � �- � � . - � � Wat roof /Sealarrt � Tum-u Prote�tors � . . . . �� � . Riser � � �4�equired Setbac�Cs . � � Water�Tight � � � From Welts �. � - � � , . . pump- . � From Property lines � � � � . � . � �edc Vatve/Gafie Valve . � � __ . .Structures/Basements.:: � '.� : � � -� i oe . . es ra�� e� a . � . . . . •� �aatslSwiict�es.�: . � � . • . . _ . _ : . _ . Surfacye`Waters . . . _ . . � . .. � � .. _ . Alann visabte and audibie � Pubiic Water Sup lies . • Eiec�ical Com �errts Vertical Cuts >2 ft . � � _ Rate m Wat+e�- L1nes . . Ap roved P Mode! Veh�le Traffic Btocpc Under Pump Ad cent� ms � � �� Pu Removal Ro elChain EasementslRi hf af 1Na • - Distribution Sys�bem � Othe� Serial Distribution ' Easemerrts Recor+ded . . ressvre an e r �tract Low Ptessure P9pe � Trf-Partate A reemerrt r. Pipe Mate�al and Grade � Valves • � . ' C�mments� . { . pcf�ct rev. 31131oy � � ,�C� ��G�n ���� �� 1��t..r�.0 ��� /o � � �� �,� � /�.�,� ��� � .�tid�.t/�y�G ��G /NjG�cuC� i �'`/ �� , c%5�.�-n/�c1s ��� � �i✓���'� ��"�/f ' -fj� � � ' �'�.r,� /i � ,�la,�/S �,cG ,�.u-�� . .G!/�� � .uae� � % � � - �