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A31 123� a W U � a --_. � B 3200 PERSON COUN'TY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IlV�ROVEMENT PERNIIT 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. Tax Map #� 3� Parcel # 23 Zoning Township Owner/Contractor 17p�{�►S , %�TYJeY,� �1,�;��'' ,,, Date /0 �/�c/ Location/Address � � � ' S.R.# Subdivision Name Lot# Z Permits m; Well and SE Comments: Date Installed by Approved by ell Permit Paid .. . . . � Site Approved �/ Well Head Approved Grouting Approved_ WELL SYSTEM SPECIFICATIONS _Semi-Public Required Slab t� Replacement Air Vent � Required Well Log �( f� Oa � �/ Well Tag 1/ ,� , _� _ . �_. , Date2'�j��(� Installed b3/ �,U`�/ � APProved � �1�5- This report is based in part on information provided the homeowner or his/her representative in the application submitted 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:\amiprolpermit.sam O1/95 rev.l.l • ,. AUTHORIZATION FOR WASTEWATER SYSTE�i CONSTRUCTION (Void sixty (60) months from date of issuanc�) DATE: -' — �IPROVE:I��vT P��II'T �: TAX I�L�P �: �_ PARCEL �: ow�,-�,�ow�+�.��s �x�s�r�r�Trv�:1�P1�Vll t� �%��'IC' GL��i� SL�DItiZSIO�i v�ti�: IlUI �(�t �� ��i,% � �1 LOT �:�_ SECTION OR BLOCK: �L�THORIZ�TION FOR CONSTRt CTION ISSL�D BY: . _ _, .. AUTHORIZATION COy�ITIONS 1. The Wastewater system construction and 'mstallation must meet all of the c ditions of the attacaed site ptan and specifications as set forth in Improvements Permit �����. Tiie const�uction and installation must also meet aIl applicable rules and laws. 2. No portion of the Wastewater system shall be covered or plac..-d iuto use uu�I inspecied and approved bythe Person CouIIryHeahh Depar�nent. 3. Any aiteraticns in site or soil conditions (including struciure loartions) ar modifiartion in use, desi3a wastewater flow, or wastewater characteristics as s�ecified 'm the associated . im�rovement permii and application, may void this authori�tion and associaied permits. 4. Conditians: Schedule 40 soIid �ine over dams Kee�sevtic 100 feet from anv we11 10 fee�t from anv nrooertv line_ 15 feet from basement wa11�5 feet from anv vart of the bouse. Kee.� well at . :.:..�'=•'•"::: % Person Requesti :� ���:,.. :. -;��� „��. '.. ::7X'.`y . �'L' - . r .x�-: .' . �{�Z;" r-� �}� --..: •'t � , -'=.�' hs: 0 0 7 ' . ' �; : x � ��: . � - - :- — -- - - • - . - _ ..::.ir. �. 'c�sr::.. _ --i. .'�..�:j!.."� . � 'f _ . �. . � �j •. 1- . � G -± � / i . � '� . � ti � �� '��" � . �a��•� � �� i ^� � � o .� ' . � ` � �1' �' • � ' � + � � �'�°; y,� ' � �.,o ,� + ,'♦ t:,< `v . ►o•: ro' � c���� • s i�11,� f TWM� . � � � � � �/ / � � ^ �, � - • .� �� � � rcr: ro� . � � � ,� ,��C �� � , ,�A r*t..w ,r •� � . 1.89 t�. �� , ���� • � �► • 4 ,► ;� " .� �° ♦ � -O i .� � 2. � i OC. � 1. 89 0� . �S ��� � '� � � t l-t�-�•O�'- � �$'�►, � ' �,�1 sss,.�r ' � s,�' . , � T i. oc. . , � �• . _ ..� �► r • � � �. . , ., . . � . A �'..,' � + � ' PERSON COUNTY ENVIRONMENTAL HEALTH PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Map #: ,�' i 1 Parcel #'�� Zoning Locatlon: Township�Q��'�f�l. � � I, , � , ►,r � Gf. ,� Subdivislon• %��,`711 �l'.CI r� ection: Type of Water SupplV: Reuuirements: Site Approved by �/�/. Grouting Approved by Well Log Well Tag � Air Vent � Hose Bib � Concrete Slab � Well Permit �iidividual 0/ . I � I ���i �� V — �� �� 1-f� -D� Lot: _ v Community Public Well Approved By: ��,%G1.�11i1 Date: ��� �� **See Attached Site Sketch** Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from any building foundation. Other conditions: PCHD, rev. 11/29/99 . �- �:u��r�rrr i�:1VVl.ltOtJP;::t�rr��i. iiiini.�:u . . _ � ' • . ir,:i.i. i.uc: ' `�---��°ic;:� `7,niav J - O tilm e�': �' y ; . J , LOC � L] O]7 �-----�.2. u-� �7 � �-- /.D1I"CC��UII�: -s"�i�F- W �c }-,- : •'' . . S . � � ! Q ��s. _... ��..i � . � t: (�:' i v orl .7V�tn�� �: � ;- ...........-- � � �1� ( .� 111 ] -• --_. ..�� �" s�"�cJV ,(�c � r y � ' J . . ...._� i; COi]CI"c1CL0�': ___ / � e %4�r ,_.(,.O[ �� �_ __ .�'� �.� s .,�� �l. .,�;� .: _.��,� ..__.` � -_. ,Dis[::u�ce Irom Nc�u-cst ]'roa,crt �� ��:1..1 _( (,.)N:ti I_It tIC:"I'((�1V ���---- Pollu[ion %Df? 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O! 1 l i , � �: ( (�',�' . �, :'.' :'. �1D:� � �NS�` : r,� ; --� ��IG ':; , ' Person County H�alth Department Environmental Health Section Tax Map #: �"�l� Parcei #: i��✓ Zoning: Township: ,_,,w►,1,(5�11 �8'1�� Subdivisiorr. �/l)(iC� SfY'Gi�.��i'i�V1_�C�dS Section: Lot: � Applicant: � V115 � �i�'�(�,1� ������ Location:� �S �1 L DI/I C�/1��'�1e1 fil �il • ,�� 6�/( C�� Operation Perm it System Type (In Accordance With Table Va): L 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. ?%�'�� uthorized State Ag nt Date Tax Map #: �� Parcel #: � �.� PCHD, rev. 10/12/99