A31 109_ � B 2570
• PERSON COUNTY HEALTH DEPARTMENT
� WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
, has been issued.
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T� Map # ,/—�- 3 ( Parcel #
Owner/Contractor ` C �GZ.� . �J l Dat
Location/Address 5� � / L �, i- e.� �(p �
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Subdivision Name Lot#
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SEWAGE 5YSTEM SPECIFICATIONS
Lot Area � , ( `��(�
ti/- Mobile Home ,/
# of Bedrooms�`�
Permits may be voided if site is
Well and Septic Layout by�
Comments: ��„M„/� n
Date /—//- � Installed by.
or
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S.R.#
Size of Tank 1 � ) ) _
Size of Pump Tank _
Nitrification Line � `'tC� f
Max Depth Trenches�� ) ��'
���o � c .� s
Approved by
Well Permit Paid L� WELL SYSTEM SPECIFICATIONS
Individual Semi-Public Required Slab �
Public Replacement Air Vent S N�+
Site Approved Required Well Log�
Well Head Approved ✓ S� Well Tag
Grouting Approved � �r► �+
�omments: (� � �li�� � r�YY1 L �i �'
: �-I I -99 � Installed by
by
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This report is based in part on information provided the homeowner or his/her
representative in the application s�bmitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contained in the application. The environmental health specialist is also not
responsible for concealed conditions on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. 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.
c:\amipro\permit.sam O1/95 rev.l.l
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AUTHORiZATI0I1 FOR WASTEWATER SYSTEM CONSTRUCTIOI�I
(Void sixty (60) months from date oE' issuance)
DATE: IC� � R�1 � IMPROVEMENT PERMIT #: ��S7 O
TAX MAP #: �: PARCEL #: D�1
OWNER/OWNER'S REPRESENTATIVE: � i �'ii1Ga�P � � � I � �S�
LOCATION/ADDRESS:
SUBDIVISION I�IAME: LOT #:
SECTION ORBLOCK:
. AUTHORIZATION FOR COI�ISTRUCTIOI�I I�SLJBD BY:
AUTHORIZATION COI�IllITIONS
l. The Wastewater system construction and instaliation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Pernut #�. The
construction and instaliation must also meet aII appiicable rules and laws.
2. No portion of the Wastewater system shali be covered or placed into use unti[ inspected and
approved by the Person County Healih Department. �
3. Any alterations in site or soil conditions (inc[uding structure locations) or modification in use,
design wastewater flow, or wastewater characteristics as speci&ed in the associated improvement
permit and appiication, may void this authorization and associated permits.
4. Conditions:
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T� �'rUROLE MILLS
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50' ACCESS
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PI.;RSON Cc)IIN'i'Y h:NV1:)ZONP,::N'I'ltil, III:ALTF1
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Date; ��3 »��_ �
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Owner: - c, ,��_,��.�-� Sh� �-
L,ocation/I�irect�ons: �w,-d �� yh . //�.-----._._.___._.._
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.,�v��v�SiOn N�ul��e: �
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Drillin� Contractor: _ ..._.----._..._.-.--.--- ..__
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WI;I.I C'ONS=I'R[1C1'(ON . � --=>�
Distance from Nearest Proper�y Lin��_.._��_��,,�s__ llist.�ncu .from Source of ' '.`�'�a
Pollution_ . � � a ��� . ..,
Total�Dep.th:. Ft. Yicld:_��___ GpM Static Wa[erLevel `��
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Water B�earing Zones: De th .F�' '`
P _fl�_ . 1 � � ._,[� � _1= i. Ft. ����. � �
Casing: Depth:� Fro�n � io---__�1 �I��. Uia,nctcr: G�; � Inches '
TYPE: Steel � Ga1v:�nizul Ste�;1 ✓ � '
X.f Steel, does owncr a>>rov�:: }�'�;; . ;�``��;�
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' Weighc: f,3 Thicicness:�, j-�cight �lbove Ground v;lnch � ���
Drive Shoc: Ycs_ �--No . .:--.�.`._._' � �'�`'��;
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Werc Problems Eiicotiiltcrcci iri Se:�tiil� �tle Crisin�t;'� Xes � No �
If 'ycs glvc rc�isou: , ::'�;�
Grou[: Type: Neat ---- _..----�- _ 'a::.,��a{
S:�nd/Cc1�1ent �✓ Coricrete �'�`s�;�
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Annular:Spacc Wi�it�� _,3_.._.Lic}Ics . . `:_�
�Yater in Annular Spacc: Y��s N� � � ��"';�
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Method:' Pum�x;c�---._. .___ I'rc:.surc � 1'c�urc;cl� .: .. � � . �:,�:�:
Dcpth: From �___�__ t�►..--- � I_ � I�t. . • . ;��
Materials Usecl: No.l3ass 1'ort(�u�d CcJncnt ' ```"'
W eight of .l � bag��lbs:��
If miature (sand, gravc:l; cuttin�;s) - 1Zatio: � t ;a,."i:�
ID Plates: Yes v No . � � :. • .. '�� :,`�s'
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rocmation Descri tion
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I HEREBX CER�ITFY THAT TI-IE �3UV� 1NFURMATXON ZS CORRECT AND;TH�
-.. T�S WELL WAS CONSTRUCI'ED IN ACCORDA,NCE W1TI-� REGULATIONS��S`
��RTH BY�T�-1L PERSON COUN�I'�' I�II;I�I_,TI-t DEPA1:'I'MEN"I'. � ..�:,
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Sibn;,lurc c�r conl;;;ctor
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Appiication Date: o �-b—I
Amount Paid: �
Rec�iat #:
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APPLlCATiON FOR SERVIC�S
Tax Mao #• �3 I
Parc�l #: � o I
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT. FALSIFiEfl,
CHANGED OR THE SITE� IS ALTERED THEiH THE IMPROVE�VIENT PERMIT AND AUTHOR�TION TO
CONSTRUCT SHALL BECOME INVALID.. �
1) Permii requested b: er/agent/prospective owner): .' e /�Q �-%S�P�
Home Phone: .��0 - �� Address: S �-e� ; e/c/
Business Phone: u� �' //.1' /v f 75 S� /
2) Name ar�d .address of carre�rt owner. s q/� -e�
3) Properly Description: Lot size:�l Township: �o� .'��
Directions to the properhr �Induding road names ar�d numbers): _
��UMl�O /�_�//r ,10.l'� n�i
Lot
4) proposed Use and Structure Description: answer each of the fo) lowing questions:
a) Proposed _, Existing JType of Strucfure:�����.h�l ��,�of.2 Width:�� Depth: S 2--
b) Number �f Bedrooms: � Number of occupants or people to be served: �
c) Basemen� Yes . No Wiil there be plumbing in the basement'?
d) 6arbage Disposal: Yes No �
5) Water Supply Type: Private �new _ or existiny �), PubiicJ CammuniiyJ Spring _
Are any welis on adjoining property? Yes_ No _ hF yes, piease indicate approximate location on the
'siie plan.
6) Does your property car�in previously ider�tifled jurisdlctional wetlands? Yes_ No �
PLEASE NOTE THE FOLLOWING:
➢ A PIAT OF THE PROPEiZTY OR S1TE PLAN MUST BE SUBMt7'TE� WITH THIS APPUCATION.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED. �,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAf�D OR FLAGGED.
➢ THE S1TE MUST BE REA►DILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMEiVT
STAFF.
1 hereby make application ta the Person Caurtty Heaith Departrnent for a siie evalua�on 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
facaiities to be piac�d on the property. I understand if the site is aitered or the intended use ct�anges, the permii sfiall
became irnalid.,, �, .
Owner o� Legal Repres�ntative
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Date
PCN�, rev. 06127/02
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Nam�. `� i Z1,cb� �r�� h� Taa Map # A 3c Parcel #� c��r .
n 5'8to � �� '�- � Section/Lot# � - -
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tluthorize Sta.t . Agent � . :� Date . ;. , � .
System c,o»tponents r�r�esent a�roximate�contours only. The coniract+or must, f�ag the system�irior to�.
Legi�sniasg the instaAa�ion to insure that�firo�'iergmde is nusintarned � .
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