A31 134Application Date: �'6-6�
Amount Paid: .�O
Receipt #:
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Tax Map #: � 3 I
Parcel #: � 3 —T
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APPLICATION FOR SERVICES
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED,
CHANGED OR THE SITE IS ALTERED, THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID.
1) Permit requested by: (Owner/agent/prospective owner): ��v �`' ��-�`
Home Phone: � Address:
Business Phone: b� '1- 50�5
2) Name and address of current owner: � � y�� w�a�,�,
3)
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Property Description: Lot size: 3�� Township: ��
Directions to the properiy (Including road names and numbers): _
�„�, �a, S��l
� eir�1' Lot # Z3
4) Proposed Use and Structure Description: answer each qf the following questions:
a) Proposed � Existing , Type of Structure: I�JI rv-��1. Width: 2� Depth: �
b) Number of Bedroomsa�'�}- Number of occupants or people to be served: Z
c) Basement: Yes_, No ✓ Will there be plumbing in the basement? � ca.
d) Garbage Disposal: Yes No � �
5) Water Supply Type: Private ✓(new ✓or existing�, Public_, Community_, Spring _
Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the
site plan.
6) Does your property contain previously identified jurisdictional wetlands? Yes_ No ✓
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBM,ITTED WITH THIS APPLICATION.
➢ PROPERTY 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 DEPARTMENT
STAFF.
I hereby make application to the Person C
system for the above-described property. I
facilities to be laced on the p operty. I �
become inva� �
Owner or Legal Representative
th Department for a site evaluation for the on-site sewage disposal
the contents of this application are true and represent the maximum
if the site is altered or the intended e cha ges, the permit shall
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Date
PCHD, rev. O6/27/02
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Applicaut:
Location:
Permit Valid for �
Type of Facility:
# of Occupants /� �'
Proposed Wastewater
Proposed Repair: �
Permit Conditions:
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Owner or Legal Represe
Authorized State Agent:
#
Y�
al,
T��x NI��� � P�.rcel #
S�uibcilivi�s�ioia , � �aii :' ' ��
iPha�s�e�Sect+ion.Lot : �
Improveme�t Permit
No Ezpiration
S,
New � A,ddition Water Supply ��' 1 I
Projected Daily Flow � o g.p.d.
Type: ��
Type:
Date:�� � �
Date: - -0
The issuance of this permit by the Health Depariment in does not guarautee the issuance of other permits. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are 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 issned 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 continne to #unction satisfactorily in the future or that the water supply will remain
potable.
- Authorization to Construct Wastewater System (Reqnired for Bnilding Permit)
* See site plan and additional attachments (_�.
Proposed Wastewater System: lSl�tt�✓1��,1Yia 1 Typ�� Wastewater Flow 7� g.p.d.
New � Repair Expansion �l Soil LTAR: � S g.p.d./ ft 2
Type of Facility: `��l��f��• Basement Yes pL No
Wastewater System Requirements
Tank Size: Septic Tank: �6� gal Pump Tank: gal Grease Trap: gal
Drainfield: Total Area: ��O sq ft Total Length �� ft Ma�mum Trench Depth l� in
Trench Width �� ft Minimum Soil Cover: � in Minimum Trench Separation: �_ ft � �� •
Distribution:
Specifications:
Distribution Bax DL Serial Distribution Pressure Manifold
S� s��� S�e�L,
Authorized State Agenr _�
Permit Expiration Date:
,�
Date: � 1 ^ q'�o -1
The type of system permitted is �Gon entional Innovative Alternative. I accept the specifications of
the permi� o�-- � �
Owner/Legal Representative: Date: �
PCHD I/17/2003
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WELL PERMIT� .
PI.EASE SEE A'I"rACHED PY.AN FOR W�LL SITE I.AYOUT
Tax Map #: 7� Pazcel # ��` Township
Applican�
Subdivisiori: W�( �(�rV {'7�{ S Section: Lot �
Location:
C��I;e L�, � —� �iy,-��e 5
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Ty�e of Water Sun�lv: D� Individual Commu�nity Pubhc
Requirement�,s� / �
,� � .�.� ,/
ite Approved bp �� � Cl-O �
Grouting Approved by (�R � -e� � ,
We11 Lo '� Z� ��-
Well T �
Air Vent �
Hose Bib �
Concrete Slab
J
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Well Driller cx�rt�!-le ���i 'C-��. �^ J �
Well Approved. Bp: � � ��V Date: � �� � ° v(
�See Attached Site Sketch'k*
.
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.
Ot�er conditions•
PQ�, rev. 09/07/Ol
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Driller ID # %
Com�p�,ny Name ,r�
D�t�e Drilled �
Grout Log
p��; ` Tax Map �1 Pazcel # �
Location: `c '
.,
Subdivision: +lN, z ��.,z�,. �',�� Lot # �
Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from Septic System (Minimum 60 feet)
Total Depth: �(� ft Yield: 2 GPM Static Water Level: � ft
Water Bearing Zones: Depth f� ft ft ft
�
Casing:
Depth: From _� to ��_ ft. Diameter: %t�, in
Type: Galvanized Steel
Weight: ckness: s/� Height above Ground: �_ in
Drive Shoe: Yes No Any problems encountered while setting casing? Yes �o
If "yes" give reason:
Gront: � " /
Neat: Sand/Cement ✓ Concrete GraveUCement
. Annular Space Width inches Water in Annulay Space Yes ��To
Method of Grout: Pumped Pressure Poured � Depth to Ft.
Materials Used:
No. Bags Portland cement N�`. f� Weight of 1 Bagc�O Pounds
If mixture (sand, gravel, cuthngs) — Ratio to
ID plates: � Yes _ No 4 x 4 slab _ Yes _ No
Liner: .
Depth: Date Installed: Grout:
Installed by:
Drillinu Lo� Location Drawin�
K.ii /
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I hereby certify that the above information is conect and that this well was constructed in accordance with regulations set forth
by the Person County Health Department. _� �
Signature of Contractor
ID # ��'�i21� Date ,3— g-��i�'
Pump Installment
Pump Installation Contractor: ,�c� f n t�"n- (�� l� State Registration Number: �L��i'7
Pump Depth: ft Static Water Level: _'7� ft
Pump Make & Model: �f P �. ,��. ��(� .�- C1r-e-; z��,� Pump Size and Rating: � hp �.IZ_ gPm
I hereby certify that this pump 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 be rovided to the well owner.
Pump Installer Signature /. /�� � _ Date: -� � PCHD rev O 1/27/04