A31 169� -+► � d
� ' b �Q � � Tax Map: #
AQplicaticn Date: . P 3 � �. .. .,� � .
Amount Paid: • U -. _. - -
Receipt#: � . . � .s2� . ParoE1'#:
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� APPLlCAT10N FOR SERVIC�S
IF THE INFaRMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT 1S INCORRECT, FALSIFIED,
CHANGED OR THE.SITE IS ALTERED THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT
SHALL BECOME INVALID. ����-��.
1 Permlt requested by: (Owner/agent/prospective owner): � � �
� Home Phon�331,�.36 �- xts Y Address: ., , r� ��� �� �e-��
Business Phone: �/,��..�r��Ie Y%%� �J.c a>; �l
. � �_
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2) Name and address of current owner: .Si4M �' �c 5 AS e�= � ��-3
` �. c�,�.�e�.�
3 ��-
3} Properly Description: Lot size: Township: n. �. Subdivision: Lot#:
Directions to the property(Inciuding road names and numbers):
t'o/ND/=sC7'E/2 /i(� , %�o/Yt v�� �l�t= M/l.G..S�r4
/ A" / L !�
4) Proposed Use ar�d Structure Description: answer eact� of the following questions: 3� � �D /
a) Proposed i/ Existing _, Type of Structure: �.oG' �¢,!� /�/ Width: Depth:
b) Number of Bedrooms: ,�_ Numbe� of occupants or people to be served: �
c) Basemenr Yes � No _ Will there be plumbing in the basement?
d) Garbage Disposal: Yes J No ✓
5) Water Supply Type: Private �/ (new _ or existing �, Public_, Cammunity � Spring _
Are any wells on adjoining property? Yes � No _ If yes, please indicate approximate location an the site plan.
6) Does the properly contain previousty identified jurlsdictlonal wetlands? Yes _ Nar�
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SiTE PLAIV MUST BE SUBMITTED WfTH THIS APPLICATION.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARI�D.
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR ELAGGED.
➢ THE S1TE MUST BE READILY ACCESSIBLE FaR AN EVALUATION BY THE HEALTH DEPARTiIAENT STAFF.
!� hereby make application to the Person County Health Department foc a site evaluation fo� the on-site sewage disposal
system for the above-described property. I agree that the contents of this appiication 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 shail
became i alid. < <
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C�wnpr nr 1 al Reorese tative � Date
Pct�o, re�. �a�7�o�
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F�h�:s�e Sect�iam`Lot �
Improvement �ermit "
�ermit Valid for � F�iv �eaa�s No Ezpiration //
Type of Facility: � New � Addztion �ater Sup�pdy �t
# of Occupants R # of ooms Projected Daily Flow ��� g.p.d. �
Proposed Wastewater System: L+�a � Type: �
Proposed Repair: vt tl��, d Type: �
Permit Conditions: 52.� Sl �OZ S�'� �f�' �
Owner or Legal Represe
Authorized State Agent:
Date:
The issuance of this peimit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicantfproperty owner to in sure that all Persoa County Planning and Zoning and Building Inspections requirements aze met This
�mprovement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement �'ermit is not
affected by a change in ownerslup of the property. This permit was issued in compliance with the provisions af the North Carolina
`�aws and Itules for S'ewaQe Trentment and Disnosal Svstems' (15A NCAC 18A .1900). Neither Per�on County nor the
Enviranmental �ealth Specialist warrants that the septic tank system wi11 continue to function satisfacton7y in the future or'that
the water supply will remain potable. � �
Authorization to �onstruci Wastewater System (Required for Building Permit)
* See site plan and additional attachments (_J. �
Proposed Wastewater System: `4V1�%�M 't�`�� � Typ� �4 astewater Flow '��.p.d.
New � Repair Expansion _ Soil LTAR: ,�� g.p.d./ ft 2
Type of Facility: � �� ��^ Basement _ Yes No
�astewater Systean Recyuirements
'Tank Size: Septic'Tank: C�D�gai Pnmp Tank: gal Grease 7Ca�ap: gal
�rainfield: Total Area:1� sq ft Total I.ength �� ft Ma�ffinm �rench Depth 1 g in
Trench Width � ft 11�i'nimnm Soi1 Cover: � in Minimnm Trenc9i Separation: � ft �� C•
Distribation: Distribntion �oa � Serial Distribntion Pressnre Manifold
Specifications: �� � � �'��" � �
Authorizesi State Ag$nt: �
Permit Expirati Date:
Date: ?
The type of system perniitted is � C entional Accepted Alternative. I acc�pt the spe�ifications of the
permit. � -'� 2��
Owne`�/I,�gal �iepresentative: Date:
' P rev.11/10/OS
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THIS SYSTF�VI H.4S �EE3V WSTALLE� IN COIiff1PL1ANe� WtiH AP.Pl.ICABLE . NORTH
C�4R�LI�A GEiVERAL STATUTES, �RUtES FQR SEWAGE TREATMENT. AND DISPOS�►L,
AND - AL:L CONDITi�1VS OF " THE IMPROVEMEi�li' PERNIIT APID CONSTRUCTION
A!lTHOR N. � .
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D; rev. 0712Q/04
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Tax MaQ # Rarc:�l # b_ System Type (Tabie Va)
Owner/App�icant � � � S�bdivision
Address/L�c�ion Ser�Pfias� Lot # � �
Se�fi�. Tank In� at� c�ow nes Ine�aa �
State�ID/date �" � Trencfi UVidth� ft.
Ca a' v . al. ' � Trench De th '� in:
Tee and Filfier � • � Trench Len �( ft.
Baffle � Trenct� G�ade - �
Sealant � ✓' Trenct� S ac9n � ��'
Riser �fi a licabie •� � Rodc De and Quai"
�'ank Ou�et Sesl `�' �� ams/Ste downs e#c.
Permanerrt Mar6cer Pr�essure Laterals � � � �
Pum Tank • Haie Spacing • ��
�+� � . � o _ �� ,��
. . �a awc �
� Wate roofi /Sealant
Riser
Water Ti ht � �
� Purrsg�
Checic ValvelGate Vatve
Alarm (visable and audibie
FJectrical Cc�mponents
Rate (apm) _ .
Approved Pump 11�ode!
Blocic U�der. Pump �
Pump Removai Rope1C
. �•Dis�ibution:Sys
Serial Distnbution
ressure an
L.ow Pressure Pipe
Appr. PiQe I�Aateriai and
. .-�- -- - -
Sleeve
Required'�Sefba�
From�Weils �
ti Q Fcom Proaertv lines
. • � �Surface Waters
Public Water �t
V.erticai Cuts >;
Water Lines
� VeFiicle�Traffic
• , �Ea$ements/t�ighf of
. Other
T- Easements RecordE
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Cornmen�s .
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WELL PERNIIT -
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map � 3� arcel # � G 1 Township:
Applicant• ' � r M-�
Subdivision: Lot #
Type of Water Supply: � Individual _ Community Public
Requirements:
Site Approved By:
Grouting Approved By: loriq�o�e
Well Log:
Pump Tag: P i� S �
Well Tag: � /
Air Vent:
Hose Bib:
Casing Height: I �1 p c�
Concrete Slab: c�
Liner:
Installed by:
Depth set: _
Grouted:
Date:
Water Sample:
Well Driller: �,Sov1
Well Approved by: Date: O�
****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 O1/27/04
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WCII CODBh ILCt�OII
Distance From neare,st Praptrty Line (Muumum 10 feet) j� f
Distance from Septic System (Minimum 60 feec} �C?�
Tota1 Depth: �� ft Yield: GPM Static Water Level: ���_ ft
Water Bearing Zones: Depth � fi ii ft ft
Parcel #
C'ssing: G.3
Dspth: Frorn �- � io �.S ft Diameter: �� in
Type: Galvanized Steei y�c� -- �
i�Veight: ..� Tfuclaiess• Height above Cround• � in
Drive Shoe: Yes ii�in • Any proble�ms eacount�red while setting c:asing? Yes :� No
If "yes" give reason•
Grout:
Neat: Sand/Cemeat �Cancrete GraveUCement
Annular Space Width inches Water in Annulaz Space Yes °�No
Method of Grout: Fumped Pressine Poured Depth to � Fk
'_1�IxteriAla Used:
No. Bags Portland cement Weight af 1 Bag ______ Poundg
If mixtwe (saad, gravel, cuttings} — Ratio ta
ID plates: Yes _ No . 4 x 4 slab ____ Yes � No
%�
Drillin� Log Location Drawiag
I hereby certify that the above information is correet and that this well was constructed in accordance writh regulations
set forth by the Person County Health Degartmen�
5i�aature of Cuntractor iD # Dste �
PCHD rev Ol/16,�02