A32 198Application Date: 1- � 6"� �
Amount Paid: 00
Receipt #: Z-
Person Countv Health Department
Environmental Health Section
APPLICATION FOR SERVICES
Tax Map #:
Parcel #:
1) Permit requested by: (Owner/agenUprospective owner): (✓� ���� ,l/9�� p�f�
Home Phone: 3.�6-3L y-/3/9 Addres- s: 60 M9r✓X; 5 L�,e �
Business Phone: }�u�dl� /''1; // 5 iUC � �5 /
2) Name and address of current owner: �A 1 c= i'�. Phe Jp5
5 95' N�.�d1c rn� 1�� K,d
._ IZoxboro NC-. �,�"1 'WL3
3) Property Description: �ot s�ze: � Township: �
Directions to the property (Including road names and nw�r pers�: �ro �.d
.� _ � ►_.. . � , _ � i _ ,, e fl � . �� . � _. _ __
4) Proposed Use and Structure Description: answer each of the foliowing questions:
a) Proposed p! Existing ❑
b) Stick Built 0, Modular 0, S'ngle Wide O, Double Wide�
c) Number of Bedrooms: � d) Number of occupants or people to be served: �
e) Basement: Yes ❑, No I�s, # of basement fixtures:
fl Garbage Disposal: Yes �, No�
g) Dimensions of Proposed Structure: Width: � Depth: �.
5) Water Supply Type: Private o(new�r existing 0), Pubiic ❑, Community ❑, Spring ❑
Are any wells on adjoining property? Yes ❑ NoA�lf yes, location
6) Please Indicate Desired System Type: (systems can be ranked in order of your preference)
✓Conventional AAodified Conventional Alternative innovative
Other (specify):
CLEARLY STAKE ALL CORMERS AND LINE5 OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for
the above-described property. I agree that the contents of this 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 as applicant, I am responsible for identifying and marking property lines, comers and making the site accessible for the
personnel of the Person County Health Department to conduct their evaluations. I understand that I am responsible for notifying the
Health Department if my property contains any wetlands as designated by the Army Corps of Engineers.
.T ,QQ� -g-o�
Owner or Legal Repre ntative Date
PCHD, rev. 10/12/99
, .
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.' PERSON COUNTY ENVIRONMENTAL HEALTH
• Tax Map #:
� Parce� a
Zoning Townshi
� Appucanr T � '" ` 1- � - - �t,. ,��
Locadon:
Subdivislon: 3ectlon:
LoC
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Improvement Permit.
A buildinq permit cannot be issued with onlv an Improveme�t Pertnit
New Repair Addition Type of Strudure �� Water Supply ����
# of Occupants ' i�� #�of Bedrooms Other
Basement? n Basement Fixtures7 r/ Q .
Projeded Daily Fiow: � g.p.d. Permit Valid For Five Years Cl No ira6on
Proposed Wastewater Syste pe: S�jg/�r� Cmr1 U�1 �� Di►�
Pump Required? Yes No � � �
Proposed Repair : c,J �� �t o�� m" y � �i ���no ut�; ,,e
Permit Conditions: � � � .
.
,.,�- ns
Owner or Legal Representative Signatu�e: 'Y1lu�.- � Date: (` Q'�'
Authorized State Agen� � � Date: � �
The issuance of this permit by the He Department in no way guarantees the issuance of other permits. The permit
halder is responsible for cheddng with appropriate goveming bodies in mee�ng their requirements. ThIs site is
subject to revocation if the site plan, plat, or the intended use changes. The Improv.ement Permit shall not be
affected by a change in ownership of the site. This permit is subject to compiiance with the provisions of the
Laws and Rules for Sewage Treatrneat and Disposal Systems of the North Carolina Administrative Code.
Type of Wastewater System
Faality Type: � br � w �
Basement? 0 Yes No
Wastewater Svstem Reauirements
Septic Tank Size• � gailons
Wastewater Flow: v � ,p.d.
Repair DExpansian 0
�t F'nctures? 0 Yes 0 No
Pump Tank Size: � galtons
�n n ��.. w
V 1�%/' �
a� /� � � �
• eP
Tctal Trench Length: �_feet Maximum Trench Depth: � inches Aggregate Depth:� in.
�'I.n�mkm �D�
Meximum Soii Cover. �, inches Trench Separation: F t on Center �n5�^�"
c f � � ��C� S./ � ��JC.f�'iOI�
Other. i lJ� � r Oli g�j
� �; -�1 �..6oU�
Pertnit Expiration Date: ((� /� �� �,-„� S y5'�I�So
Authorized State Agent: � 1' Date:-�D/ . •.� 1' 'n wa.�� W� �(c,.o
0.ro� 5 � �csn� 0 -
The type of system permitted does 0 does not differ from the type specified on the application. I accept
the specifications of this permii Y
�� I
Owner/Legal Representative Signature: Q N1�� � Date: �� �
� � PCHD, rev.11/18/99
� �
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� .' P�rs�n C:wnty �lealth. �partment
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- 4petation �-.Permi�t �
. Sjrsber�t Type (In Accordance Vllith Table Va): �
. .„
TtBS SYSTEl1 HAS BEEN INSTALLED !N CONIPUANt� Wt'il�! APPLICA6LE NORTH
CAROLlNA pEl�IEEiAL STATUTES, RUI.ES FOR SEINA�E TREATYENT /IND DISPOSAL;
•AND ALL CONORIONS OF 7HE IYPROVBIEM' P�tY1T � AND CONSTRUCTION
AUTHO T10M.
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. PERSON COUNTY EAIVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE �A'
�� % �
T� � � Paresl #
Zoning Townahip � � `
-T �� 1 n_ t 1.; .�i� �l�/.� _
AppUcanC
Locatlon:
Subdhriston• Sactlon: �
� Weil Permit '
Tvpe of Water Suaatv: Individual Community Public
0
Requirements:
Site Approved by � � �
Grouting Approved by � o�
Weli Log � t�' . .
Well Tag ✓ �
Air Vent � -
Hose Bib `� �
Concrete. Slab . �
Well Driller
Well Appro
Date: //- D/� ?�� /�
'"""`See Attached Site Sketch*'`
Wells must he 10 feet from �property tines.
WeUs must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
. 3 � �i .
' �� PCHD, �ev. 11/29/99
0
Date: �o � -o/ '
Owner: %r7'� r�c.
Location/Directions�
Subdivision Name: _
Drilling Contractor: Z�
PERSON COUNTY ENVIRONMENTAL HEALTH
%
WELL LOG
SR#
Lot #
WELI. CONSTRUC'I'ION a
Distance from Nearest Property Line 1 v Distance from Source of
Pollution ( G �
Total.Dep.th: l.�d FG Yield: � GPM Static Water Level Q2.S-" Ft.
Water Bearing Zones: Depth �S� � f F[. S�� D�:/Ft��Ft Ft.
Casing: Depth: From 6 to,��Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel
If Steel, does owner approve: Yes No
� � Weigh� Thickness: l S'� Height�Above Ground: /� Inches
Drive Shoe: Yes ✓ No _
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" give reason;
Grout: Type: Neat SandJCement / Coricrece
Annular Space V�idth � Inches
Water in Armular Space: Yes No
_ .. Method: Pumped � - Pressure � Poured � - -
Depth: From O to � O Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes � No � �
� 4 x 4 slab Yes � No
I HEREBY CERTIFY THAT THE ABOVE INFORMr�TION IS CORRECI' AND THAT
THIS WELL WAS CONSTRUCTED
FORTH BY�THE PERSO�I C�`vi�TY
IN ACCORDANCE WITH REGULATIONS SET
HEALTH DEPARTM % .
�..C� �,.o_
� _ _�
Signature of Cont � ctor Da�c
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