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pp t tlon Date. .h b n�.��) 9�
Amount Paid• �D � � � n -
Rec� /�i/ v� !/
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APPLICATION FOR SERVIC�S
Tax Man #• Z
ParcEl #• �.�J�
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT 1S INCORRECT. FALSiFiED.
CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT Af�lD AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID. - ;� � /�
�Q�t (.,c71c
1) Permit requested by: (Owner/agentlprospective owner): �I10��,P�m ��
Home Phone: � Address: � J
Business Phone: _�3h-Sg ��553� 1C�rw (�C z�, 3
2) Name and address of current owner: �7_¢r�a �L ; a ��� ��'`�'`�"��
•' L�
Properiy Description: Lot size: � Township:
Directions to the property (including road,names and
Lot
��1
4) P'roposed Use a d Structure Description: answer e ch of th follflwin questions:
a) Proposeci � Existing , Type of Structure: �Al�tKr�e� .�/ � Width:_ Z� Depth:�
b) Number df Bedrooms: � Number of occupants or people to be served: �_
c) Basement: YesJ No ✓Wili there be plumbing in the basement?
d) �arbage Disposal: Yes No .�
5) Water Supply Type: Private �(new �or existing�, Public� Community� Spring _
Are any weils on adjoining property? Yes_, No _ If yes, please indicate approximate location on the
� site plan.
6) Does your property contain previousiy identified jurisdictional wetlands? Yes_ No ✓
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKEDa� ,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAlCED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-siie sewage disposal
stem for the above-described property. I agree that the contents of this application are true and represent the maximum
cilities to be placed on the property. I understand if the site is altered or the intended use changes, the permii shall
me invalid.
Owner or Legal Representative
g��
Date
PCiiD, rev. 06I27102
� buSN Y t- (�r<K i r�� ., rti-CJviv LUu�v ,►, iv . L.
�.:NOVEMBER 1994, HAMLETT—JENNINGS & ASSOCIATES
JOHN J. JENNINGS L-3052
�oo o ;� Zoa ,� 8oa
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8AR GRAPHI inch = 200 ft.
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PERSON CO,._ � _
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"'��-� M�°'� ,;DATA��_�TABLE
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' LEG ° -�`BEARING. DIST.
��`,�ti, . � : � .. N ] 3 '.10;'.21 ° W . 54 . 13 '
;2 N06'22'29"W 195.91'
�,'`.�,-�;`�� t _3 N01'S1';1.9°E -. 79.00'
s��- r4 �N;1,8'.38' 26"E -' ] 46. 89'
M�� �a �� r:5 �;N32.'.56!54°E . . 63. 15'
��' hr ' ;`-� �fi ;N44; 14:!:17"E :: : 207.89'
�,,��.�� �, �-� �.�> tJ%i9 00��00°E ,.-209::80'
�-� � ^�;;& h�f4'�'00'DQ."E 2i0.07'-,
+�+�;: r ,.9� YN4i`t19' 15"E 94:36'
I'0 N18 50'45"E 10.00'
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OLD,�ROAD
NOEL BRADSHER.: � !�
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Applicant:
Ta�x M��E� P�rcel #
S��i h ci!i v i�s�i o i�
Ph���s�e�Sectioii Lot u
�
Improvement Permit
Permit Valid for k Five Years _ No Ezpiration
Type ofFacility: ';�,1� � (�,�_oS�w. New h Addition Water Supply I��+�
# of Occu pants �„�,�. x # of B�ooms 3 Projected Daily Flow 3�� g.p.d. �
Proposed Wastewater System: ��„�„� s►-ro��.� �,�•'fic. � . Type: �� �
Proposed Repair: ��ouc.s�c� C��' / rQw.�_��1 � Type:
Permit Conditions:
Owner or Legal Represe
Authorized State Agent:
The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicant/properry owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met Tlus
Improvement Permit is subject to revocation if the site pi$n, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownership of the property. This permit was issued 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 continue to function satisfactorily in the future or that the water supply wi11 remain
potable.
Authorization to Construct Wastewater System (Required for Building Permit)
* See site plan and additional attachments (_).
Propose� Wastewater System: ��►���►� Type ��, Wastewater Flow � g.p.d.
New � Repair Expansion Soil LTAR: . a�� g.p.d./ ft 2
Type of Facility: �r L. �-�.:� . Basement Yes K No
� Wastewater 5ystem Requirements
Tank Size: Septic Tank: ��a gal Pnmp Tank: ^ gal Grease Tra.p: �-- gal
Drainfield: Tota1 Area: I'Y�_ sq ft Total Length y U� ft Mazimum Trench Depth 1 g`�'s �•� e
Trench Width �_ ft Minimum Soil Cover: Cn in
Distribution: x Distdbution Box Serial Distribution
Authorized 5tate Agent: � � ,_X
Permit Expiration Date:
Minimum Trench Separation: � ft
Pressure Manifold
Date: �- 3—o y
The type of system permitted is � Co entio al Innovative Alternative. I accept the specifications of
the per�nit.
Owner/Legal Representative: � ` Date: � �
PCHD /30l2002
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Appiica
Locatio
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T��x M�� � - Parc�el �
S�uhd'ivi�s�ia�i
�Ph�•s�e Sec�tio�r����Lo�t �
�peration Perrnit
System Type (In Accordance With Table Va): �
THiS SYSTEM HAS BEEN 1NSTALLED IN COMPLIANCE WITH APPLICABLE NQRTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF T}iE IMPROVEMENT PERMIT AND. CONSTRUCTION
AUTHORIZATION. �
����,GCS . � � - �-�7 0� �
Authorized State Agent � -- �- � Date
" 5.2� o� .. ..
Instailed By: �J �: .��� S . Date:
. � � �, s.� �- � � .
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�PCHD, rev. 07/29/02
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�1 SE�T1C i'AMK IRiSPIE�'�ION �NE�b°CLISi' (Type il - )
Tax Map #�t,3a Parcel #�� System Type (Table Va)
Owner/A�piicant� \ Subdivision ^
Address/Location - ' � . Sec/Phase '-' Lot # �
Septic i'ank ni a ate tn ca on nes n�t�a a#e
St�te ID/date 5'�,j� •�3'� Trench Width 3 ft.
Capaciiy. . gal. Trenctt. Depth /g" in. �
Tee and Filter ✓ . Trench Length 6' ft. 3
Ba#iie ,/ Trench Grade � � i �
Sealarrt � Trench S ac9n ✓ � �
Riser if applicable Rock Depth and Quaiity ✓
Tank Outlet�.Seal Dams/Ste owns etc.
Permanent Marker h Pressure Laterals
/Sealarrt
Riser
tn�.,+e�
Ho(e Spacing .
o e ize �
Pi e� Sleeve
Tum-ups/Protectors � .._—
Required Setbacks
Fmm Welis �: .
Pump From Property lines �
; Checic V�IvelGate Valve Structures/Base�ents.. ..
. nfi-s� on o e �tc es rainage ay�
. Fioats/Switches �� � ... . _ � . Surface Waters .
Alarm visabie and audibie Public Water Supplies
Electrical Com onents Vertical Cuts >2 ft.
Rate gpm � Water�Lines
� Ap roved Pump Model Vehicle Traffic
Biocic Under Pum � Adjacerrt�S stems
Puma Removal Roae/Chain Easements/Right of W�
Low Pressure Pipe • �
Appr. Pipe Material and Grade -
�
Other
Easements Recorded .
ert e perator orii
Tri-Partate Aareement
y
Comments
��
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pcf�d rev, 3/13I01
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IE��na-�������:]l IC-3L��.It�I�.
Iy
Drille-r ID # r, • _
Com�p�ny N�me . ,i� ` � '��
,
D�t�e Driiled � — �' `
Grout Log
py�,n�: rEl1'�� ��r�'�Y� Tax Map � Parcel #/c5�
Location:
Subdivision: Lot #
Well Constrnction
Distance From nearest Property Line (Minimum 10 feet) �lL�
Distance from S tic System (Minimum 60 feet) �O
Total Depth: � ft Yield:�� � ,�- GPM Static Water Level: �� ft
Water Bearing Zones: Depth CvJ i� � ft ft ft
Casing:
Depth: From � to �� ft. Diameter: � l�</ in
Type: Galvanized Steel �
Weight: Thickness: /� Height above Ground: �� in �
Drive Shoe: �Yes No Any problems encountered while setting casing? Yes %I�To
If "yes" give reason:
Grout: -
Neat: Sand/Cement Concrete GraveUCement �
. Annular Space Width inches Water in Annular Space Yes No
Method of Grout: Pumped Pressure Poured ,�' Depth �� to �ZS Ft.
Materials Used:
No. Bags Portland cement N 6 Weight of 1 Bag t5'D Pounds
If mixture (sa�i, gravel, cutting Ratio 2 to J_
, ID plates: � Yes _ No 4 x 4 slab / Yes _ No
Liner:
Depth:
Date Installed:
Drilling Log
Grout: Installed by:
Location Drawing
From To Formatio ,ty{ v�d�,�- < <
O 7 S �� �
� 10 4�.�
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I hereby certify that the
by the Person County I�
Signature of
is correct and that this well was constructed in accordance with regulations set forth
ID �-X �1��1 Date �O ' 02 ^�' �i�
Pump Installment
Pump Installation Contractor: �' State Registration Number: ���
Pump Depth: �U ft Static Water Level: ��- ft �
Pump Make & Model• Pr(l �c��� Pump Size and Rating: �—hp l6 gpm
I hereby certify that this pump was installed and the well head completed according to the Person County Well Rules in effect
on ttus da�e and that a copy of ' o d has be n provided to the well owner. .
Pump Installer Signa Date: �-a'� � PCHD rev O1/27/04
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WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map �3a� Parcel #)sa Township: {-�� ry, J�
Applicanfi ��Q �,�e�a•
Subdivision: Lot #
Location: 15"�S Cy,,�� �n,l�� H.a,� (�i cr, I.,xln�- �-��c Ct.. 1� � L a.
Type of Water Supply: �Individual
Requirements:
Community Public
Site Approved By: (�S 3-a�-�/ Liner:
Grouting Approved By: ('S� 1•0 ��z� - Installed by: �
Well Log: S� -`� -a �i � Depth set•
Pump Tag• �S Grouted:
Well Tag:. C� Date:
Air Vent: �'� -S -��/
Hose Bib: Water Sample:
Casing Height ��,C'�
Concrete Slab: .% L,�
Well Driller: 'r'� �oQ � ��
Well Approved by: Date: l�-S-��/
****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.
Otherconditions: ���ua ��-C S��
PCHD rev O1/27/04
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SITE SSETCH � �
Natrie i�� ( Q�A�. ��,.�,.,.�,. _ Tax Map #� Parcel # �SZ�
��., 1 ' ��� . Section/Lot# .
s 3 ��p � - .
Autho �' 'd Sta.t Agent � Date� �• :
.System component� represent approxtmate contour�s only. .Tbe contractor must, flag the ���� ��
. system ��rior to� be�lnnin� the �nstallat�on to insure tbat i�rnper xrade is maintain�d. . .,
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