A30 96Date: —2�-- q �
Owner:
Location/Directions:
� ' ' ' �
PERSON COUN'lY LNVI1tONMLN'lAL kIEAL'1'H
WELL LOG
LI�
SR#
Subdivision N�une: � . . � Lot #
Drilling Contractor: C�►J K t n) E� t 1.1..1 AM SO �1 . t1J G.
WELL CONSTRUCTION
Distance from Nearest Property Line Distance from Source of
Pollution
Total.Dep.th: Ft. Yield: ��J GPM Static Water Level Ft.
Water Bearing Zones: Depth Ft. Ft� F� �t.
Casing: Depth: From�_to 8� Diameter: � Inches
TYPE: Steel � Galvanized Steel ✓
If Stecl, does owner approve: Yes No
� Weight: Thickness: . �� Height Above Ground: Inches
Drive Shoe: Yes No � ;
Were Problems Encountered in Setting the Casing? Yes No �
I� "ycs" givc r�cason:
Grout: Type: Neat Sand/Cement Coricrete `
Annular Space Width �2. Inches
Water in Annular Space: Yes No
Nlezhod: Pumped Pressure , Poured � ✓ .. . - .
Depth: From O to � Ft. - �
Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes ✓ No � �
4 x 4 slab Yes�—No .
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.
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Signature of Concrac � Date
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Pe�son Couniv Health Deaartment
Emrironmentai Hesith Sedion •
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�) Perrn� rsq�,satied (ow�erragenttprosr�edtv. c+�nar3: �-%
Ow e
t�Ome Phana S 9� S�a.� Addr+a� _
Buslnees Pt�ne:
Z) Nams and addr+ess of currertt o+�msr: �" �'-� �.�=�'t.�
.S�' � . Pl�iy- � —a
3, �p�„ �an: I�t s� � p
Di� bo the Prop�Y A� taed namee
C�,cur�.o-�� .s'.� � �--►�
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- �`,? �'-s Si/
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' -~�.. �? 23'� / � 3'�� 9�.��.� .��
/.�.�' �' .3 ii/�.7,�"' � � \ " .�.��
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iS �- �iiS � Yr�nr� /�� ��
6lv,z'� .t. :i� �� % .�.�;,( ,
4) Prcpo�ad Uae and Stru�ture Descriptlan: answa' each of the tolbwin9 q�on�
� a) � �g o
b) Stldc Moduiar 0. Sin91e Wide Q Dout�e Wtde �
c) Numbr ledcnorns: 3 � � cq Number of a«xip�ts or people bo be serve� �-
8) Basement Yes Q Na !f yes, � of baserne�rt �dtuex
� Gerba� Dtsposal: Yes
g) Dtmensiona of Propoaed Strix�tus: Wldttx �6 p�;2b' .
� � �P�Y TYP�: ��(new�or e�ds�ng �. Pub% 4 ��aY 4 sP�9 ❑ ., • �` y�y ,�,,;.��..
• Are atry we0s cn adJoi�9 Pr� Yas�i [Vo � ff yes. bcatlon .�.� .,��4 �i�� U
/�
��. tndica�a Deaired 3ystan Type: (aystsms c�n ba ra�csd in order af yaur prefetencsj
,�Conwrttlonai _A�o� Canventlonal
_ AlLernative In�ve
�
C� � b�-j .�Z.�,.�� `� �".�' �-" o� -.� . -cL--�
.� �� �� ��.� �
v sT� aLL co��s �wu �.wes oF n{e ��rr.
sTa� n� cor��s oF au. r�oPosm sn�ucruRes.
PLEASE ATTACN SURVEY PLAT OR STTE PUW TO THIS APPLlCATION
��,� 'z"L `�%'�`�'
! hereby make appitcauon- to the Person Caunty Heaith Department for a site evah�tion far the on-s�ie sewaga dtsposai sys6em for
the above-deap4bed �cperty. t agree thst the contesns of this app�cation are true and tepresent the maximwn i�c� to be
piaced on ttia properiy. I understand if the site is al6ered or the ir�tended usa changes, the permit shail become irnatld. I understand
that as appitrarrt, 1 am raa�oaaibie fa� ide�yin9 ��9 P�P�Y �, comers and meldng the �te a� for the
P�nnei of the Person Ceu�ly Fieaith De}�artment to condud their evaivaHona I�d that I am r+espo�bie for notUyin9 the
H�Department ifi my property �ins any wetlands as designated bll '� �l �� ��� � ,
..�u� /� �� /0 30- � �v a
�' . �wn�' or L�sl R�r�er�ve . Da�e -
PCfiD. tev 10t1?!99
_. �� PEi�SON COUNTY EiVVIRONME3VTAL MEALiH �
�_ - PLF.�►SE SE� ATi'ACHE� PLAN FOR SOIL AREA AND S'YSTE�VI LAYOUT
Tax AAap ii: it"�� �� C� PucNf � �
Zoning Tawnshlp 11is 1� }'Qr � .
� �Q��,C i �e ���
i
Locatlon:
,
d ,pG•�t GISS�� o r�.
Subdiviaion: SKtion: La�
tmprovement Permit
New °'�Repair Addition Type of St[udures � Water Supply Zi� �
# of OccarpaMs #•af Bedrooms � Other
Basement? �� 8asemetrt Fodtu�es?�Q_ .
Projeded Oa�7y Flow: 3� 0 g.
Proposed Wastewater System
Pump Requined?� Yes ,
Proposed Repair : . �H q D ✓A
Permit Conditions: ACo� P,o S�
a�
Owner o� Legal Represenha8ve
Authorized State Agerrt:
Permit Valird
_ Per►v2
r�
Years 0 No Expiraticn
G'on[aur.
lo �
Date• � �6 "- ��
Date: �2 � 1 D U
The issuance of this permit by the Heahh Departm� in no way guatantees the issuance of other p�rmits. The permit
holder is responsible for chedcing with appropriate goveming badies in meeting their reguirements. Thts sifie is
subject to revocation if the sifie plan, plat, or the irrtended use changes. The Improvement Permit �hall �ot be
affeeted by a change in ownershlp of the site. 7his peRnit is subject to compliance witfi the provisions of the
Laws and Ruies for Sewage 7reatme�t aad Oisposal Systems of the North Caroiina Adminlstrative Code.
Authorization To Construct Wastewate� Svstem (Required for Buiiding Permit)
Type of Wastewater System _�� YP�'�0 � Wastewater Flow: � d.
�•P•
Facility Type: 3 F�`'• �f` : . NewJ��epairO�cpansio� ❑
Basement? 0 Yes o Basement Fuchues? 0 Yes�
Wastewater Svstem Reauirements
Septic Tank Size: Pi 4ff gallons Pump Tank Size: 'r— gaqons
Total Trench Length• �� feet Maximum Trench Deptt� �[� iru�tes A99�9ata Depth:,L� in.
Maximum Sal Cover. � inc�es Trench Separatton: � Feet on Center
Pem�it Expiration Date:
Authorized State Agen�
�-lt( /05—
The type of system permitted ❑ does ❑
the specificatlons of this permtt
CJate: �Z. I .
dif(er from the type specified o� the appiication. I acr.spt
OvmerlLegal Representative Slgnature: ��,. l/ ' Da�• S– /�- o�
fl
• PCHD, rev.11/18/99
. . , •,
� . . .
� � • � � � � � App��catlon �: � 3n
� ' ' . . Tax MAp �: �
. Paraei #: _._____
�� Penon County Hsoith Dapettmerlt , � .
Environmental Heaith 8ec�lon
' , � � . . � : - $ir� s��rc�.
� � ��� ,n(�;�,�� � � �
` r -� , • 8ubdivlelon/8eotfon/l-ot#
_ ppli s N
. �-3=-� .
Authorixed 8tat ent Date . � �
Syrlser aon�ponsn/i r+qp�esenf apprazlmate conlowra on�y. Ths contrnctor r»urtJlag fArt ry�tem
. rlvr to � �n tA�alnalallM�on to ln�ara ttiar ro er di it malnt nad
0
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PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE �tAYOUT
Tax 1raP #: � � v � � _ Ptral � —__--�
Toning Tawnshtp � � r "�
A�� ��1, �' l�
`�� � � r �
�o�w,; �p�(� i'b�C - J� C7 S T S SZ i�Or�OV�
s„bmwwoa: �� . �
. Weil Permit ` �
. .% • • Public
Tvae of Water Suaatv. Indrytdual Commun�iy .
�
Reauirements:
Site Approved by fh� �'-a � o/
Grouting Approved by
Wel( Log ,��� iS' �� �-e
Well Tag /h� � _
Air Vent ��;,� � �
Hose Bib ��
Concrete lab �'f��
We11 Drilier: � ��i'--.'�� f(�' j�,�a��ts�--
Well Approved By: /6� � �c�
Date: 8�''�3 -o�
**See �Attached Site Sketch**
� Welis must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Welis must be at least 25 feet from any building foundafion.
�
J Other conditions
� � PCHD, rev. 1�/29/99
� .
Y�RSUN COUNTY ENVIR�NH�NTAL H�ALTH '
,y .
WELL LOa '
Date: �"3"� � �� � .. L SR# � � ,
Owne.. _
1.,ocation/Directions: . .
L�t �E _
Subdivision Na.mc: �..,, �� �.m SC�; S-,� c
Drilling Contractor: +�«uri�� w�
,
Dis�ancc from Ncarest Properry Linc _ Distuncc from Sourcc of �
P�llucion
Total.�ep,th: F� Yield: GPM Static Water Level F�•
Watcr Bearing Zones: Depth t._�Ft. F�._ �t•
De th: From.�_�o Ft. Diamc � � Inchcs
Casing: P . Galvanized Steel �
'I'YPE: Stcel � -
If Steel, does owner approve: Yes No�
1i�eighc: _ Thickness: • � Height Above Ground:_ Inches
Drivc Shoe: Ycs No _..—
Werc Problcros Encountercd in Setting the Casing? Ycs^_____. No______
i; "ycs" givc rca.�on:
Gr�u�: Type: Neat __ Sand/Cement __ Concrete
A.nnular. Space Width I ���chcs
Water in ,Arulular Spacc: Yes_�_.,_ No____.�..
. Mathod: Pumped � Pressure_ I�ourcd •�_
Depch: From O to � Fc,
Materials Used: No. Bags Portland Cement______ Weight of .1 bag__lbs,
If mixture (sand, gravel; cuttings) - Ratio: �o -- .
ID Platcs: Ycs '�_ � No,_____._
4 x 4 slab Ycs ✓ No _
I HEREBY CERTIFY THAT THE ABOVE TNFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FOR'1`�-I BY�'THE PERSON COUNTY HEALTH DEPARTMENT.
, . .
. �! � 5 r�: _�y
Signat�irc of Concract � Datc
Person County Health Depariment
Environmental Health Section � �
Tax Map #: _T � Parcei #:
Zoning: Tawnship: '
Subdivision: Section: Lot:
��) c
Appiicant: � `-"' r
�/� �C�'� �� �
Location: '? "� G� ` _
Operation Permi�
System Type (In Accordance �th Table Va): �� r-
THIS SYSTEM HAS BEEN INSTALLED lN COMPLIANCE WITH APPLICABLE NORTH
CAROLlNA GENERAL STATUTES, RULES FaR SEWAGE TREATMENT AND DI$POSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZATION.
� - �� . as o�
Authorized State Agent � Date
5c��t
e U'�
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h�
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e=ro^�'
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Fr�
�%oc�ar,
s y�'
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Tax Map #: Parcel #:
S�
�-- 5 � o0 0
ST� /h' a
G, .- 5y
i
�a=�3
�3 = (06`
LW _ ���i
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T�^ �3�,
PCHD, rev. 10/12/99