A32 200,�a iication �ate• G"� 1-! /
qArnouret Paid: �.7 ��
�ec�icat #:
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9��rson Cauntv Health Det�artment
�<:_�nvic�nmental Hea�th Section
" APPLICATION FOR SERVICES
Tax Maa #:
Parca! #:
a � ����
!� r��o
1) Permit requested by: (Ow�er/agent/prospective owner):�
Home Phone: Address:
Business Phone:� - �Z( `-
2) Name and address of current owner.
3)
4)
Property Description: �ot slze: � ` �ownshtp:
Directions to the proaertv Mcludina road name:
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r �- . � � � �ccy ^-' — ��
Proposed Use �a Structare Description:�answer each of the foliowing quesUons: v
a) Proposed�; Existing 0_ �
b) Stick Buiit �, Modulard�i le Wde �, Double Wide ❑
c) Number of Bedrooriis:� d) Number of occupants or people to be served:
e) Basement: Yes �, No yes,�basement fixtures: �. � - _
� ����ae Dt�po�al: Y�� ❑ p;t� __ .. _d _ � _ _ . _. .. .,: ., _ , _ . . . . _ .. .
g) Dimensions of ProposedrStructure: �dth: � d Depth: ��--
5) Water Supply Type: Private �'(new � or existing 0), Public �, Community �, Spring 0
Are any wells on adjoining property? Yes � No � If yes, location
6) Please Indicate Desired System Type: (systems can be ranked in order of your prefeience)
Conventional _Modified Conventional _ Alternative. _Innovative
Other (specify):
CLEARLY STAKE ALL CORNERS AND LI(dES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACN SURVEY PLAT OR SITE PLAPI TO THIS APPUCATiOPI
I hereby make apptication to the Person County Health Department for a site evaluation for the on-site sewage disposal system for
the above-described property. 1 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 aftered or the intended use changes, the permft shall become invalid. I understand
that as applicant, I am responsible for identifying and marking property lines, comers and making the site accassible for the
personnei of the Person Courriy Health Department to conduct their evaluations. 1 understand that I am responsible for notiiying the
�eaith artment ifi roperty contains any wetlan as designated by the Army Corps of Engineers.
/ ►/1'l ✓I-c_ � GJ �S - C O�y /
Owner or Legal Re e ative e
PCHD, rev. 10/12199
a
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land;
and
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surveyor's
above.
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Date
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Chartes E,Hall
D,B. 265-270
D,B. 133-177
Charles E,Hall
D,B, 265-270
D,B, 133-177
� Unda S,Hall
,�, D.B, 208-348
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I N 85"23'05'E 282,82 Ctot)
•�F, 249,.2 "*�r. 33,70
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322,62
S 82°48'18'W
Charles E,Hatl
D,B, 265-270
D,B, 133-177
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S,R, 1119
N 07`32'32'W
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Control Corner
� S 07"57'48'E
133,09
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S 0 �°1�6'41'E
S 07°43'43'E
— 91,11
S 07'43'43"E
— 43,39
S 07'09'S9'E
39,63
S 07'll'42°E
— 66,98
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PERSON COUNTY ENVIRONMENTAL HEALTH
LEASE
Tax Map #: � Parce! # Q� Township'�C�� PIN
�P��� .- . • . , _ C,har�,���o�-�� we.� ���,S�ti� �o�
Locatlon: U -5�
improvement Permit
New � Addition Type of Structure Water Supply
# of Occupants # of Bedrooms _'� Other
Projected Daily Flow: s2,� g.p.d,� Permit alid For. ❑
Proposed Wastewater S em: ��✓ i
Proposed Repair.
Permit Conditions: .� LT,l��� - o .�`T Z
Owner or Legai RepreseMative Signature: Q.
Authorized State Auen�yl�
System Type�_
Date: � � `� � �% `
�te:�/� lo/
The issuance of this permit by the Health Depa(t�ent irino way guarantees the issuance of other permits. The permit holder is
responsible for checking with appropriate goveming bodies in meeting their requirements. This site is subject to revocation if
the site plan, plat, or the irrtended use changes. The Improvemerrt Permit shall not be afFected by a change in ownership
of the site. This permit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatment and
Disposal Systems of the North Carolina Administrative Code.
Authorization To Construct Wastewater Svs#em tReQuired for Buildinq Permit)
Wastewater System Description: ,�e.t�✓ Wastewater Flow: ��c� g.p.d. Type:
Facility Description: New ❑
Basement? O Yes o Basement F'ixtures? 4 Yes ❑ No
Wastewater Svstem Requirements
Repair ❑ Expansion ❑
Tankage: Septic Tank size d000 gal. Pump Tank size gal. Grease Trap size
Trenches: Total length �D_� ft. Trench Width �_ft. Total Area /7�O A sq. ft.
gal.
Max. Trench Depth:1� in. Aggregate Depth:� in. Soil Cover. _�, in. Trench Separation �ft. on center
Permit Expiration Date: �
Authorized State
•Ses attached site plan and addendum
permit conditions.
�
The type af system permitted ❑ does ❑ does not differ from the type specified o� the application. 1 accept the
specifications of this permit
OwnedLegal Represerrtative Signat �6�0. . Date: _! ' I.O �
Operation Permrt
System Type {in accordance with Table Va� �
This system has been installed in compliance with appUcable Nortlt Carol"u�a Genera! Statubes, laws and Rules for Sewage Treatrnertt
and D 1, and all conditions of the Improvemerrt Permit and Construction Authorization. Issuance of this permit implies no
guara at s stalled will function property fo� any given period of time.
j�-I�-o 1
orized State Agent Date
PCHD, rev. 03/07/01
Parson C�unty Health. Departrnent A 3�
Es�vironmental Heaith Section T� jl�aQ �: /"�'
� � P�rcai #: ,�.d d _
��o.r� e S �'.-c,..� a 1'�'E S14E'a'C1-� . _ . . --
-� APPiic�t's Name � _ Subdlvision/Sec�on/Lot# .
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. orized State er�t ��e � �
Syyat�t,�ornp,,,rar� r,epreaex� app�raximate cm�ta�rs only.
prior to b� dis �i�R to iRture tlta+t yr�i
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Person County Health Department
Environmental Health Section
Tax Map #: �a`� Parcel #: ���
Zoning: Township: ���Y ��K
Subdivision: �� / � Section:
Applicant: Ch�r��.S Ca l d c,� �l (
Location: U �S 12 ��
Lot: �t
Operation Perm it
System Type (In Accordance With Table Va): �
THIS SYSTEM HAS BEEN INSTALLED IN COMPUANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
A ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
UT OR,IZA�'ION. �
Authorized State Agent
�D - � 1 '�l
Date
�tl 11. � � , M z �v
_ �
M ,
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Tax Map #:
Parcei #•
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PCHD, rev. 10/12/99
PERSON COUiVTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL StTE LAYOUT
�- a� �,� 3�� . .
Tax WP �:
2oning
Township E�S�• v Far�c
�P���n� C��-t�s c�. ��l � t. fr
�tio�: � �� 5 S �- �
� �
Subdivislon'
►J /.� sealon• ��c
Tvae of Water Suapiv:
Reauirements•
Well Permit "
V Individual Community Pubiic
Site Approved by �� ��� �-� �
Grouting Approved by � � 11"�"0►
Well Log T� ✓`��t � -a-o 2
Well Tag l��c— /�-�'o/
Air Vent �`2�i'�. /-Z �'�'�
Hose Bib ��� �-� �—�'' -
Concrete Siab �� ���
Weli Driiler
Well Appro
Date• � - Z-�Z-
**See Attached Site Sketch**
Welis must be 9 0 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. 11/29/99
�5/25/1992 22:58 336388594� EvANS t�LL ARILLING
��� ' �' ' ---
..r---�'�'""_
,Date:—.j..1- �.-.�� ;
Owner: �.� .� ;�, ;, �
�.ocat�on/�3i�r.: c�: s►�:
Subdit�isiot. ?�':��::
Drilling Con�.r:�:,�!
Pi:tts�x r,qtJNTY ENvIRONMENTRL A�AT,TI•i
WELL LOC
• r .__ _.... .__w "' . :' _ � LU� 7�
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L
PAGE 01
Aistance #'Xor� ,:��::�:��:t Propercy Linc . D�s�.�ncc f�rom Source of
Pollution
�
_—_,�c:c.::.;,:. a:1�.+-S
�'ota� Aep.th:�:S' :� Ft. Yield:.^�_ GPM Static Wat�r �.,evel Ft,
Water Bearing lr�;,��,_ Depth __�'�___Ft._ , j�2. Ft. Fc. Ft.
Casi.ng: llept,,, t•-�7m o �a���c. Diameter: b%_Inches
�'YPL•: Stee;_... . _ Galvanized Stecl ✓
If Stc.<..:. ;::;Ls owner' app�rove: X�s No
Wci�i�t; _.'.,�3 'IhSckness: j d�£( Height Above Ground:_,,,,,,�,�_Inches
i/
Urivc >'tu:e: Xes �--- No
Wert. !'�«-;1cros Encountered in Setting �he Casing? Xes_____�„ No �-.---�
Zr ";��. , �. : cason:
Grout: Ty�x:: '�{�1t Sand/Ccmcnt �''� Concrcte._._
Annz,i;�: � ��acc Width_ _� Inches
Watcr ir. ,1zululax Spacc; Yes No �--'
_ Mcr�,a:i: �}�„mped Pr:ssu�e Poured �/ �
F)epth: �=;�c,m D to�� Ft.
Matcrials Used: No. Bags Ponland Cemenc Weight of .1 bag, 9`� �bs.
lf mixc�:r,• (sand, gravcl, cutdn�s) - Ratio:��_ to l
ZU Y���u�;:- Xcs -�� No
� _______._
4 x �l ::;<;� Ycs ✓ No
z N�REBY C�K�`I1 ��' TI�AT THE ABpV� T�VFpRMA'i"iON IS C4RRECT AND THAT
T�S ��LL ti�';1S '�C)N.STRUCT�� �t ACCORDANC� VV�TH R�GULA`FTONS 5ET
FOR�'� gy •I•c j;: �: ?E�SO�t CvvivTY HE,AL�'H UEPARTMENT.
� ' _�- O 1
Signaturc of Con�ractor Datc
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