A32 204_:
Apalication Date:��2;'y ' /
Amou�t Pai____ c�: �" �..f
' Recei #• �`�
Tax Map #:
Parcel #•
Person CountY Health Department
Environmental Health Section
, APPLICATION FOR SERVICES �
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❑ Improvements Pertnit (Recorded Lot) - 5150.00 ' O Well Pertnit (NewlRe faceme�t - 5125.00
Improvements Pertnit •(Unrecorded Lot) - 5150.00 ❑ Existing System Inspection - 5100.00 �
❑ Improvements Permit - 3100.U0 � Cl RepairlReplace Existing System Permit
(Mobile Home ReplacemenUAddition)
n �,..,���.,��,,., e„�ti,,,;.�,��� _ s�nn nn ❑ Redraw Site Plan - 375.00
1) Permit requested by: (OwnerlagenUprospective owner)��/�1_d,�,����
Home �hone: �4- i3�.3 Address:
Business Phone: g4-'�79,070 7 � > > - �' • r� `s'��
2) Name and addres , of current owner: � � 1¢�,/��_
�i/�'!1J�i��/1'.d.i�
3) Property Oescription: �ot stze: � Township:
Directions to the qrope�ty (IQcluding road name
4) ,Proposed Use a Structure Description: answe� each of the following questions: ,
a) Proposed , Existing ❑
b) SticK Built �, Modular , ingle Wide �, Double �de ❑
c) Number of Bedrooms: ,,,� d) Number of occupants or people�to be served: �_
e) Basement: Y�:s 0, No �If'yes, # af basement fixtures:
� Garbage Disposai: Yes 0, No f&�
g) Oimensions of Proposed Structure: Width: �Depth: �8� .
5) Water Supply Type: Private new �existing 0), Public 0, Cammunity 0, Spring �
Are any welis on adjoining property? Yes ��0 If yes, location
6) Please Indicate Desired System Type: (systems can be ranked in order of youc pr.eference)
onventional �Modified Conventional
Othe� (specify):
_ Altemative . Innovative
CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SRE PLAN TO THIS APPLICATION
1 hereby make application to the Pe�son County Health Department for a site evaluation for the on-site sewage disposai 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 accessibie for the
personnei of the Person County Health Department to conduct their evaluations. I understand ihat I am responsible for notifying the
Health epartment if y property c tai any wetl ds as designated by the Army Corps of Engineers.
O
Owner Legal Repre nt ' e Date
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I���na �����.�.�.Il IL IC��..11�]�.
Applicant: �! � C
Location: � , , , _
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T��x M�C� • P�rc�et # .. ;
S��hci'ivi�s�ion
Ph��s�e Sec�t�ion Lot #
�pe�t� a,� - /� �- ,� �1���; . _ .. - , : - - -- --
Improvement Permit
Permit Valid for Five Years No Ezpiration '
Type of Facility: ' � New �ddition Water Supply �_
# of Occupants a,� # of B drooms Projected Daily Flow ��p g.p.d. � �
Proposed Wastewate System: Iq,t) Type: �
Proposed Repair: Type:
Permit Conditions: _ 5-P� �jf7-Q ��Q-�}�+ �
Owner or Legal Representative Si ture• Date: � 2� b Z
Authorized State Agent: � Date: --a
The iasuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirementa are met. This
Improvement Permit Is subJect to revocatlon If the eite plan, plat or the intended use changes. The Improvement Permlt Is not affected
by a change In ownershlp of the property. This permit was issued in compliance with the provisions of the North CarolIna �Laws and
Rules for Seivage Treatment and Disposal Svstems' (15A NCAC 18A .1900).
�- Authorization to Construct Wastewater System �Required for Building Permit)
* See site plan and additional attachments (_).
Proposed stewater System: �,U`Q,✓V11� �� � Type d+!—�t Wastewater Flow �g.p.d.
New � Repair Expa sion Soil LTAR: � O g. .d./ ft 2
Type of Facility: � � ,� Basement _ Yes �o
Tank Size: Septic Tank: � gal
Drainfield: Total Area: �� �i sq ft
Wastewater System Requirements
Pump Tank: gal Grease Trap: �
Total Length d U ft Mazimum TrencL Depth �
Minimum Soil Cover: � in Minimum Trench Separation: �_ ft
Distribution:
Specifications:
Distribution Box �erial Distribution Pressure Marufold
Authorized State Agent: _�
Permit Exnira ion Date:
gal
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Date: �` � � �
The type of system permitted is � Conventional Innovative Alternative. I accept the specifications of
the pernvt.
Owner/Legal Representative: � Date: Z 2 ,Z�
Operation Permit
System Type (in accordance with Table Va)
The system has been installed in compliattce with applicable North Carolina General Statute, Laws and Rules for Sewage Treatment and
Disposal, and all conditions of the Improvement Permit and Construction Authorization. Issuance of this permit does not guarantee that the
wastewater system will function properly for any given period of time.
Authorized State Agent: Date:
PCHD rev. O1/23/02
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OE�ORIS a. HAWKINS
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_ _. ...... -r� ��l:.;::�: �` I �� �� : .. � par��� �• G�P � a � .
� Zoning: Townahlp: ' �
� � . 9�bdivision: � ��n�: . . ,3ectlon: Lo�
.' APpli�art� l � � .
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� C, �ration P'ermit �
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. , System Type (!n Accordance W�th Table Va): �
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THIS SY3TEM HAS BEEN INSTALLED IN COMPLIANCE 1NITH APPLICAHLE NORTH
CAROUNA GENERAL STATUTES, RULES FaR SEWAGE TREATMENT AND DISPOSAL.,
A�ID ALL CONDI'�IONS OF THE IMPROVEMENT PBRMIT AND CONSTRUCTION
AUT�IOWZA N.
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Auth State Agent - Date
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PERSON COUPITY EP 1���R �� S�L�YOUT
, pLEA,SE SEE ATTACHED
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Towt�hiP
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l.owtio�
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SubdWMlo�
Well Permi� '
Tv�e of Water Suaaiv: Individuai _ Commun'ity , Puliiic
Reauinements:
Site Approved by � ,
Grouting Approved by � ✓ � -p2
Well Log ✓
Weli Tag ✓ � �
Air Vent .D�
Hose Btb �f(� .
Concrete Slab �
Well Driller._ I�,�r V� ��. � -
We[I Approved By: � �-�� �'����
Date: 6"� `�- �2
*�See Attached Site Sketch**
Well� must be 'f 0 feet from propetty Gnes.
y,yells must be 100 feet from septic systems. �
� Wetis must be'at least 25 feei from any building foundation.
Other conditions: .
PCHa, rev.11129l99
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IE��s��� ����.IL IL--3i��.11�]]�.
Owner: /
Location:
Subdivision:
Dri�lller ID � _ .�
Com:pany Nr�,me ; _ � �
D�te Dril!Ied
Well Log
Lot #
���
Tax Map � �, Parcel # ����,,
Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from Septic System (Minimum 60 feet)
Total Depth: � 7 ft Yield: �_ GPM Static Water Level: � ft
Water Bearing Zones: Depth�� ft��� j ft� ft ft
_.
Casing:
Depth: From _� to ft. Diameter: •� in
Type: Galvanized Steel ra�
Weight: T7uckness: ti%.2� Height above Grounci: � in
Drive Shoe: r/Yes No Any problems encountered while setting casing? Yes �1'�Io
If "yes" give reason:
Grout:
IvTeat: SandlCement _j,� Concrete GraveUCement
Annular Space Width inches Water in Annular Space Yes No
biethod of Grout: Pumped Pressure Poured Depth to Ft
Materials Used:
No. Bags Portland cement Weight of 1 Bag
If mixture (sand, gravel, cuttings) — Ratio to
ID plates: Yes _ No 4 x 4 slab _ Yes No
Drilling Log
Pounds
Location Drawing
From To Formation
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I hereby certify that the above information is coirect and that this well was constructed in accordance with regulations
set forth by the Person County Health Deparhnent
Signature of Contractor �� �' ID# f�,2 Date ��� ���
'� PCHD rev O1/16/02