A32 208,,� � lica�ton Date: '4 "�6'�` �
�enount Paid: �0 , 0 C �. � l S � � �
Recai #: � : S �ya1.S�/
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4�srson Countv Health �e�artment
Environmentai Health Seciion
APPLlCAT10N FOR SERVICES
Tax s'l�ao �- � � �
�arc�! #: � � �
--�,
t3y rd s.Cr�.e �
IF THE INFaRMAT10N IN THE APPUCAT(ON FOR AN (MPROVEiNENT PERMIT IS F,4LSIFIED. CHANGED. OR THE SITE IS
dLT1ERED, THEAI THE IMPRO!/E�AENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID.
i) Permit requested b�y: Own�ent/prospective owner): � ��. a!�
Home Phone: `! C�i - � �5�� Address:
Business Phone: =7 i�r -"�3 �- ��:-wc e.. 3 O.Z
2) Name and address oficumerrt owner: ��� ST��
0
��� e orv . ar l�G
3) Property Descrtption: Lot size: � Township: 13 u /"6
Diredions to the property (Including road names and n�mbe �: _,,
���
�►.�C_ �20.
4) Proposed Use and Structure Description: answer each of the following questions:
a) Propased �f Existing ❑
b) Stick Built Modular Q, Single Wide ❑, Double Wide ❑
c) Number o Bedrooms: 3-�- d) Number of occupants or people to be served:
e) Basemertt: Yes 0, Na t�1f yes, # of basement fixtures: ' . __.
fl Garbage Disposai: Yes 0, No ❑ --_ -_ - (� ,
g) Dimensions of Proposed Strudure: Width: Depth: ��� d Sc� '�`� �'t' � 1�' 't'Lc�'t'`
U
� Water Supply Type: Private �(new � orexisting 0), Public Q, Community �, Spring ❑
. Are any wells on adjoining property? Yes ❑ No � If yes, location
6) Please Indicate Desired System i ype: (systems can be ranked in order of your preferenca)
✓Converrtional ,_Nladifled Conventional ,_ Altemative Innovative
Other (specify):
CL.EARLY STAKE ALL CORIdERS AND UNES OF THE PROPERTY.
ST�KE THE CORNERS OF ALL PRaPOSED STRUCTURES.
PLEf1SE ATTACH SURVEY PLAT OR SiTE PLAN TO THIS APPLlCATION
I hereby make application to the Person Counry Heaith Qepartment for a siie evaluation for the on-site sewage disposal system for
the above-described. property. I agres 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 irrtended use ct�anges, the permit shall become invaGd. I understand
that as appiic:ant, I am responsible for identiiying and marking property lines, comers and making the siie accsssible for the
personnel of the Person CouMy Health Department ta conduct tf�eir evaluations. I understand that I am responsibie for notifying the
Heaith Department if property contains any wetlands as designated by the Army Corps af Engi ee
' . aE/�C�/ � �
� wner or Legal Representative D e
PCND, rev. 10l12199
����t�� �����V� ��i�J�Rd�A9�1E���L H���'�.
TaxiVlap.:. �` 3oC Ps al��_,Tawnsttip P!N
tlppftcan� Q Su�divisfort�/i/lY� ���_ ----PhasdSec�on LotSF �
L.ocation• IJLI��� � ���I+Qi/�G�IG` -
�t�"it9�OV�t1'1�1'1� ���'Tl11$.
New,`,�ddition Type of Structure 3D� I�? WaterSupply
# of Occupartts��2� # of Bedrooms � Othef System Type�,
Projeded Daily Flow: � D g, .d. Permit Valid For.'f�Five Years ❑ No Expiration
Proposed WastewaterSystem: �Dit-Il•
Proposed Repair. ��i���
Permit Conditions: .�C�- S� ���✓�
Owner or Legal Represerrtat'v ignature:
� �.wwkw � . C Date: l — � - ° 3
Authorized State Agent
Date: ��� oC�'��
The issuance of this permit by the Heatth Department in no way guarantees #he issuanca of other permits. The permit hoider is
responsible for checlting with appropriate go�eming bodies in meeting their requirements. This site is subject to revocation if
4he site ptan, plat, or the iittended use changes. The lmprovemerrt Pennit shatl not ba affected by a change in ownership
of the sifie. This permit is subject to comptiance with the provisions of the Laws and Rules for Sewage Treatmerrt and
Disposal Systems of the North Caroiina Administrative Code.
Autt�orBzai�on To Canstruci �iUast�water Sysiem �Reauired ��r �uildinc� P�rmitl
Wastewa#er System Desaiption: 1���► Wastewa#er Flow: ���_g.p.d. Type: `�t'r"�
Faciliiy Descriptior�: �' ' Plew li$ Repair � Expansion ❑
Basement7 C� Yes "�1-No Basement Fixtures? ❑ Yes o
Wastewater Svstem Requirements
Tanicage: Septic Tank size � �i�d gal. Pump Tank size gat. Grease Trap size gaG
Trenches: Total tength Z V" ft. Trench Width � fi. Total Area �d sq. ft
Max. Trench Depth: �� in. Aggregate Depth:� in. Soil Cover. `r in. Trench Separation �ft. on center
Pertnit Expiration Date:1,Q — oZo�`�0 t�
-•--
Authorized State Agent /YLi Date: t ����ro �
*See attached sibe plan and addendum pages for additional permit canditions.
The type of system p�ermitted � does C� does nat differ from the type specified on the application. t acc�pt the
spec'�f'tcations of this permit
�Ownerli..egal Represerrtative Signature: %� ��-�-- �� � �te: � �= �3
��eration Pernnit
System Type {in acxordance with Tabls Va)
This system has been installed in compliance with appltcable Alorth CaroCam General Stah�bes, Laws and Rules for 8eMrage Treatrnent
and Disposal, a�i all conditions of the Improvemerrt Permit and Conslruction Authoraa6on. issuance oi this peamit impf'�es no
guaranbee that the system inst�alled uriil function lmoPedY for a�ry given period af time.
Authorized State AgeM Date
_ PC�1D, rev. 03/07/01
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A�plicarr� �G���i e � � �^ -
Location: n .-� �
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� � : System Type (in Acr.ordance With'Tabte Va): ��
'B'HIS SYS'fE�ifl HAS• BE�M 1!�lST�►L.LE� 9[� Ct3MPtl�+NCE.��H �PL1C�►BLE N�R�
C�►ROU�► GEllIER/�L. STATUTES, �(�ULES F�� S�IAGE'TRE�►i'i�iE�iT �ID i�tS�OS�H.., .
AND ALI. CDiVI91T1�PIS ..OF Yi�� t91APR��99�E�i'� PE��? AN�. �COidS�UCiiOI� �
-AUTHO OiV- � � ' . . . _�.. .: � .: .
. ,�' � ,/V,�- � , . . • _ . . '��-( S' d3� ' • . .
.. � . � uthar¢ed tate Agent � - � . � � � . .' .� � ' � Date .
Insfalled �` � V.�f � - • ' . . •Da�Ee: . �' 15 a� . ^ -
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T�,: lUl2¢� � ���- ��ca� � a - Syste�rt Type (T�ie 1�aj . .
, DuvnerfAp�i�c�rrt Siabdivisaon �
. }�ddr�..ss/Lns�tion � Se�lAnas� L�t #
. ���ac �"as��C � a� ��n n� n .
. St� !D/da�e j Tr•e�ctt l�lidih ii. ✓, .
t;apaciiy, al. � Trench. Depth _ t in. • .•
Tee and Flt�r � �� Trench Len . Z J ft
. BafFte � Y'renci� Grade - .
Sealant ' 'i'rens� Spacing • �
Riser ifi applicabie) Racic Depth and Qual'�iy
� � Tank Ouffei:�Se� . � � � � DamslStepdo�s �eta. . �
� Peemanerrt Marfcer . . _ � — .. Pr�ssure Lai�rals . -- . .
• � �ra� Tank .—. . . Ho1e �Spacing � . � . • �. � . � . -
� . � gate at� � . � o e izs � � — �
. . � Gapac'riy. ' . . . ' .gal. . . : .. . Pipe Sieeve . ' " . �- .
� . . � V1laierproofi ISealat� : . . _ � . Tum-upslProiectors � ' � � � ' � � .
. _ . Ris�r . ' � � . Re+c�in� S�ac�: . . � - � � .
Vllaier Tight . From iNells : - �
�ue�sp ,,,,_ From Propetty fi�ies �
. �ber,k Val�t�/Ga#e Valv�e : . ... , S#ructures/Baseme� . � • � �
. � .: . . �ti�-sip � on o e � - � . � . � ... es rainage ays �-'- -
_ :... -: . � �ioai�JSwi�c�t�es = � . . � . ... . . . � . _ . � �Swface��llVaters _ .
� �4[arm� visable and audibie Public Vlfater Sup iies ✓
Eiectticaf Camp�nerrts vertical C�tts E>2 ft. �%
Rate gpm � ilUater Lines '
Ap�roved Pum Modei Vehicie Traffic
Block��lnder Purnp -' �1d;acerrt�Systems �
Pump Re�noval l�op�/C�tain.. �sem�ntslRigt� ofi Ways .
' �Dis�ibta#�+�n S�tesn ' �cr ,
. S"eriaf. Distribution ' � Easemerrts Recorde� .
' resscue an �� ' pe r orrtract
� Lovv Pressure Pipe � Tri-Pa� Agre�me�t
Appr. PiQe lVtate�+al and. G�ade �
Valves .
� � �man��' �
, .
. �r;,� re�.r. ?d131�1
. ���5�� ��31��� ������M��l�'�L �E.�,��'�
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7��� � 3�. � �� � 0 � . �
ZoninB Tow�hiQ
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,,,� � � u,�(� �rK�,� � � . .
- � -- �� ss �� �C�� � ��,K� � � -�
� �� �� soetton: � `�
Submvisiaa: �
. Well P@nrdt ', '
T�►w
e of Water Su 1: lndividual Community Pubiic
Reauirements:
S�te Approved by�� � T��
Grou�ng Appr,,cf"v bY l� - -
Well Log �l
Well Ta �
Air Vent
Hose Bib
Concrete Slab
Weli Dri11er: ' � �" _.---
W�11 Approved By: �-c ,�11� � Date: �'� ��d 3
. ;
*'"See �►ttached Site Sketc�*�'
Well� must be 10 feet from property lines. �
�1�eits must be 100 feet from septic systems.
elis must be �at least 25 feet from any building foundation.
Other conditions:
PCHD, rev.11l29/99
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��� S� ���� �� D�� �D � � a�—�
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�����������.� ���.��� D�o Dr�D0o�1 3-�i-a�
Grout Log
Owner: bU r�r, ;. C/� ,.�,-� _ Tu� Map �� Parcel # i��
Location:
Subdivision:
Lot # �
Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from Septic System (Minimum 60 feet)
Total Depth: 20o ft Yield: S GPM Static Water Level: � ft
Water Bearing Zones: Depths3� ft 41 ft/90 �. . ft ft
Casing:
Depth: From �_ to L/2 ft. Diameter: (o �/ in
Type: Galvanized Steel �_
Weight: Ttucl�ess: , r��3 Height above Ground: /� in
Drive Shoe: _�Yes No Any problems encountered while setting casing? Yes �No
If "yes" give reason:
Grout: /
Neat: Sand/Cement t/ Concrete GraveUCement
Annular Space Width inches Water in Annular Space Yes No
Method of Grout: Pumped Pressure Poured ✓ Depth �_ to 2 O F�
Materials Used:
No. Bags Portland cement ��`�S `` Weight of 1 Bag � Pounds
If mixture (san gravel, cuttings) — Rario to
ID plates: �es No 4 x 4 slab es _ No
Drilling Log
Location Drawing
From To Formation
O pticY ; �o/ta1
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�oX�ao��
I hereby certify that the above information is correct and that this well was constructed in accordance with regulations
set forth by the Person County Health Dep e t.
Signature of Contractor ,� �� ID# s ��- Date 3� �l�-d3