A31 88Amount paid 1psoi
p � (7f� �Q
Recei t Il
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ck.� �o� a
Improvements Permit(Established/RecvrdedLot)
�mpFovements Permit (Unrecorded Lot)
improvements Permit (Mobile Home Replace�
Improvements Permit (Addition)
�--- `
. ( .Pc�..�..�.
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D�te
Reinspection of Existing System (Loan Closing)
_ Repair/Replace existing Septic System -- ,,
✓Permit for New Well
ace Exis[ing Well
1, permit requested by: :
owner/prospective ownec
A rir�racC• . _�uX ��.^%�d
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H
ome Phone #: c//0-3(0 �1 Ff'/� �
usiness Phone #: y/e-s9%-� 33
Name and address of current owner:
E
7. Dimensions or Proposed Structure:
Width:
.T1PTfj'1' � • .
8. What type (if any, additions, expansions, oc
replacement is anticipated to the structure or facility .
that this sewage disposal system is intended to�serve?
I .
9. Water supply t}•pe: '
private �j . public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No �.
IIf so, identify location:
Property D cription: Lot ize: �� ���c
Tax Map : - � /" I0. Type of structurelfacility: Froposed: �Existing: �
Parcel#• � , Type of dwel�.ing:
Towns i:' _ House: � Mobile Home: L Business: ❑
P .. .
Type of business:
pirections to property: State Road #& R� � Number of Employees: .
�mes,�tc. C.iO�'',''s''� - . .
"�j $ $ Number of bedrooms: �
� f �' � S� ��'"�'" �� `"�` �' � - Garbage Disposal? Yes No �l
-. Basement? Yesl�No�I If so, # of basementfixtures:
6. Number of occupants or people to be served: ��
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES• .
I hereby make application to the PerSon COl1IIty �Calth Departitletit for a site evaluation for the on-site
sewage disposal system for the above describe� property. I agree that the contents of th�s application 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 shall become invalid: I understand that before an Improvements Permit can be
issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to-the Health Dept. wi�iin 60 DAYS af[er the date of the evaluation of
� the site by the Health Dept., this application shall become voctf and all fees paid forfeited.
W
�
z
Si cc� Owner or Authorized Agent
Permit Issued ❑ Signature
Permit Denied ❑
Plat Observed ❑
SIAPE (%)
SOA.TDC'[VRE(12•36IN.) •
�NDY. LOAMY. MYEY, NOTE 2:1 CL�I�
SOIL SiRUCiURE (12•161N.)
uv�v sons�
SOIL DEPi}i (IN.)
RESTRICI7VE HORiZONS (!N.)
NPERVIOUS S'[RATA. ROCK)
SOIL DRAINAGFIGAOUNDW ATER
7CTFRNAL R II�7FRNA[.)
F]t
SOA.PERMFJIBILRY
'FRCOLAATION RA'!�
AYA3LABLE SpACE
, SfTECLASSh7G710N(SEEBELOPn
OIL SFAIES '
Date
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S-SUITABLE PS.TROYt170NA11.YSUiCAO[,E ll•tlPtSUlTABLE
RECOMMENDATIONS/COMMENTS: - �
SITE CLASSIFICATION DIAGRAM (Include� Soil areas, property lines, r
areas, wells, water bodies, slope patterns, etc.)
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ams, gullies, wet areas, fill
C:VIMIPR0IDOCS�APPSECS�1 FINANCEPC
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B 2282
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.
Tax Map # � rj � Parcel #
Zoning Township C,� r
Owner/Contractor �� c�-k ('�-nP_e_r ate �- 2a 9�
Subdivision Name
Lot#
SEWAGE SYSTEM SPECIFICATIONS
�ir Lot Area -�'j , 5� �1 /4 C Size of Tank ��j (� O o,f�Q
� �/ - Mobile Home Size of Pump Tank N( A
ness # of Bedrooms 3 Nitrification Line �-{p� `� 3' �TA-Q =. 3
Max Depth Trenches � y "
Permits may be voided if site i
Well and Septic ayout by �
Comments: � � (
Date
ell Permit Paid
by
� � �lo �P�c� I��m-s�
or intend d use changed.
s� (' � c�� /�� — E�c�.P
� -r,a Approved
a� 3-�Q-�$�
SYSTEM SPECIFICATIONS
Individual f Semi-Public
Public Replacement
Site Approved ✓
Well Head Approved 3 �'
Comments:
Date
Installed by.
Required Slab
Air Vent _
Required Well
Well Tag C
Approved
This report is based in part on information provided the ho�ieowner 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 i� the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
�
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: � oZ-� - 1�
TAX MAP #: ;
IMPROVEMEI�IT PERMIT #: � �
PARCEL #: �
OWNER/OWNER'S REPRESEI�ITATIVE: � ��p-�- C� t' 2 e-�
LOCATION/ADDRESS:
�i
SUBDIVISION NAME:
SECTIOI�I OR BLOCK:
LOT #:
AUTHORIZATION FOR COI�ISTRUCTION ISSUED BY:
AUTHORIZATION CONDITIOI�IS
1' ' i
l. The Wastewater system constcuction and installation must meet all of the conditions of the
attached site plan and specifrcations as set forth in Improvements Pernut #_[��� The
constniction and installation must also meet alI appiicabie rules and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Health Department.
3. Any aiierations in site or soil conditions (including structure Iocations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authocization and associated pernlits.
4. Conditions:
Person Requestin�: � CI3��"
CREEK
INE
MP ' lpp ���
IS
N05'02'07"W �
34.79' MP /
N16'19'21"E
50.68'
��
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JIMMY E. GREER
VICTORIA J. GREER
D.B. 158, P. 66
P.C. 1, P. 7
` �74�47`lyn
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6 O J`� N���24'2S„W 152.04' NS
N82'S8'08"W 156.29' �-
R/(/�/ '- N83'S3'45'W
►/ _----------___ NF
3�a�� q � � .
g �,� �
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'�'' � � P�RSON COUNTY ENVIRONMENTAL H�ALTH
. � �� � WELL LOG �
� . Date: ���:�-�.Q,1�4 � S� �_ � - SR# - .
Owne.. -
�C�iT t M�
Locatior,/Directions: � .
r .. 1!
Sub vi sd ion Namc: .
Drilling Contractor:
�� � �
y�rLT Y rr�rT�t'RU�I'L.4I�I
Distancc from Ncarest�'roperry Linc -
_ D�st�ancc from Source of
Pollution �(�jj GpM Static Water Level r�
Total �cpxh: F� Yield: . F� F�.� ���
Wacer �eating Z�r►es: De�th t• viches
� to Ft. Diamc �
Casing: Depth: From Galvanized Steel
'I'YPE: Stcel No_____.__
If Steel, does owner apProve: YeS ; Height Above Ground:_.______ 7nches
. � Weigh� Z'hicltness: • ,
Drivc Shoe: YCS l�� - • r
Were Problems Encountered in SettinS the C��g? Y�=—"–" No"_
� I: "ycs" givc rc.:�on: � -
S�d1c�ent _ roncrete_
Grout: Type: Neat, chcs �
Anniilar. Spac� Width No__
W 1i8Y lri AT}�,11113� S�GC: YCS�.r.� i011rGC1 '�.L� .�� �
Method: Pumped;� Ftessure_____.._.
` Uepth• �IDl,i _ _O W���r��
Materials Used: No. Bags Portland Cement---- Weight of 1 bag,.._._.....lbs.
. �atio: to
Xf mixture (sand, gravel; cuttings) . , •
7D T'latcs: Ycs,_ '� N� - ,._ .
,, ., � ����, vP� � No _ _, '
I HEREBY CERTIFY THAT THE ABOVEYNFORMr1TION 7,SI,H REGU A1'IONS SET
THTS WELL W�1S CONSTRUCTED HEALTH DEPARTMENi.
FORTH BY�THE 1'ERS�N COUNTY ,
.;}`; • • 3-���, � q
Signaruc of Contract • Datc
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' �CREEK
w INE
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MP ;�._ ��_00 � IS
JIMMY E. GREER
VICiORIA J. GR6E
p p.C158; P: 7
_-..,;.
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J , + `
1�
N05'02'07"W-�/ MP / S74'47'19��E . , _
34.79' / 766.82' TOTAL
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208.81, '�__ � • . . � a•_
' _1�_�s9 37 � 46"W NS '�_ - - — _ _ _ _ - -
__ 152. 61 � Ng — — — — .A
NS '
SD ��_� N71 •¢� �4j „�y N77' 24'8� „ NF 152 ;04's N83 53 45■W
,� 47
"�- - 25 W N82 58 08 1V
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