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Aonitcatiott Date: 1°? �� Q ^ �� 3 Tax Maq #•
.�maunt �aid• ��� d-�
RecE : i�arcaP�:
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�If THE INFaRMAT10N IN THE �►PPUCATION FOR AN IMPR�NE7IAENT PERM�I' 1S 1NCORREC'r, FALSIFiED
. CHANGED. OR THE StTE IS ALT'ERED. THEA1 THE IHA�FiOVEiNENT PERMR AND AUTHORIZ�►'i10id TO .
CONSTRt1CT SHALL BECOME IN1/ALID. ��
1) Pem�ti# rsquested by: (Owner�agent/prospe�re ownerj:�Qti� �'� i72c�iYlt.rz.�.�. G1(�l -i 3 2•�� ��
Homa Phone: � 3G � - � $a�, �� Address: � : 3 '
Business Pf�one: `'�"`�
2) iVame attc! �ddress of caurent awner: G�- .�a� � .a-�� � il J� ��� � ��- `a ( �j
3) Property De�cription: LoE size: S/ �-Townshlp: �i�J Subdivision: Lot#� '
Dire�tians to the properh/ (lnduding r�ad names-and numbers): o.��,.�,.: _.�, �',� �f'�'„�,L u.c�,� � .
. ,�u�,-, .� 30 � .
4) Propa�ed Use and Structure Descriptlon: answer eact� af the following ques�ion�: �
a) Proposed �, Existing . Type of Struc�ure: � Width: �� Depth: �v
b) Num6er of �edrooms: �_ Number of occupants ar peopla to be served: �_ •
c) Basement Yes . Mo � WW there be plumbing in the•basemenl?,�_
d) 6arbage Oisposal: Yes � , No „�, -
� W�' �PP�� �1Pe. Privabe �, (new _ ar existfng j, Pubiia� Commw�ftY'� SP�9 � .
Are any wells on adjainin9 property? Yes� No _ If yes, please indtcate appmulmate I�ri on the
. site pi�rt. .
8j Doss your property containprevlousfy identtflsd Jurtsdictional wetlanc4s? Yes No
PI.�ASE NOTE THE FaLLOWING:
➢ A PL�T OF THE PROP�iZTf OR SI'CE PLAiNI iNUST HE SUHMITTE� W17N THIS APPL1CA710N.
➢ PROPEitTY LINES AND CORNERS MUST 8E Ci.EARLY d1ARKED. •,
➢ THE PROP09Ei� LOCATION OF ALL 3TRUCTURES ilAU9T BE STAKE�D OR FLAGGED.
➢ THE 9iTE aAUST �E READILY ACCESSiBLE FOR AN EVALUAT]ON BY THE �iEA►LTH DEPARTMF.iYT
S'i'AFF. � �
I hereby make appilc�#ion to the Person County Health Department {nr a site evaluation foc the on-site sewage dispasal
system for the above-described property. 1 agres that the cor�tents of this applic�ian are true and represent tk�e maximum
faciii�es to be plac�d an the property. I understand ifi the site is altered nr the ir�tended use cnanges, the permit shaU
became irnaild. •
Cwner or Leg�t' Representative
/� - /(v - 0 2 �r'
Date
Pc�o, ��. astz�in2 � ':
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26,05 TL�TAL ACRES .
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Applicant:
�Location:
T��x M�� Farc•-el � - •
S�uhcllivis�ioii
Ph��s•e Sect.ion Lot #
Improvement Permit
Pex mit Valid for �ive Years _ i�io Ezpiration �
Type of Facility: ` � f
# of Occupants of Bedrooms
Proposed Wastewater System: (' D vt.v�v
Proposed Repair: .j ,�tvte�vot�iU�2
New � Addition BVater 5upply �e�
Projected Daily Flow �� g.p.d.
Type:
T�pe:
Permit Conditions: � j�� �rE�rc-� ' � �
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/property ovvner to in sure that all Person County Planning and Zoning and Building Inspections requirements aze met This
Improvement Permit is sub ject to revocation if the site plan, 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 Disp,osal SXstems' (15A NCAC 1SA .1900). Neither Person Coauity nor the Environmental Health
5pec3alist warrants ttiat the septic tank system will continue to function satisfactor�ly in the future or that the vt�ater supply will remain
potable. .
�Autho.rization to Const�uct Waste�vaier System �Reqnired for Building lPermit)
* See site plan and additivnal a#achments (_).
Proposed Wastewater System: .���vl,(�,.�,�i vl�tR � Type�� Wastewater Flow �� � g.p.d.
New � R.epair Ex ansion � �o�l LTAI[�: •�� g.p.d./ ft 2
Type of Facility: �� �S „ Basement _ Yes lC No .
. Wastewater System Requirements
Tank Size: Septic 'Tank: ,�C�al Pnffip Tank: gal Crrease Trap: gal .
Drainfield: Tota1 Area: l o� Oo sq ft Total Length �dc� ft 1VIazimum Trench Depth 1 S� in
�Vidth � ft 1Vlinimum Soil Cover: �P in
ition: Distnbution Box � Serial Distribution
�
Authorized State Agent: �
Pennit Expuation Date:
''- �
Minimum Trench Separation: ft
Pressure Manifold
Date: o� 'i o� `� 3
The type of system permitted is �Conventional Innovative Alternative. I accept the specifications of
the permit.
Owner/Legal Represeniahve: �Q�.� LQ,l.,L � Date: �'�� �IJ 3
PCHD7/30/2002
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ACCESS EASEMENT•��
P.C. 12. P. 391 � \ '
P.C. 12, P. 514 � 1
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I HEREBY CERTIFY THAT TfiE SUBDIVI
DEPICTED HEREON HAS BEEN GRANTED.
PURSUANT TO THE PERSON C0. SUBDIV
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PLA
NNING AND Z�
ADMINISTRATOR
COY T. HAWKINS
D.B. 136, P. 509
' � MP N83'33' 48"W 34 ,.Sg , ! �' �
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+ TRINITY D. OAKLEY � �� j �
MELANIE L. MURRAY
� D. B. 329 , P. 688 „S�
� P.C. 12, P. 514 �� 1 �
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RAINEY HAWI<INS, JR.
AND OTHERS
,8. 184, P. fi16
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NORTH CAROLINA PERSON COUNTY
I, __ JOHN_J ._JENN I PJGS _____ , CE
SURVEY CREATES A SUBDIVISION OF
PERSON__ COUNTY. �YITNESS MY Hf
_16__ pAY OF ___JAN____, 20_03_.
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PROF S IONAL L D� S�1/ YOR ,`
I, _ JOHN J__JENNINGS _, CER
PLAT WAS DRAINN UNDER MY SUPEI
AN ACTUAL SURVEY MADE UNDER i
(DESCRIPTION RECORDEO IN NlIL
PAGE _195_, ETC.)(OTHER); TH
NOT SURVEYED ARE CLEARLY INO
FROM INFORMATION FOUND IN BO
__/__; THAT Tf1E RATIO OF PRE
CULATED IS 1:__LO _000+__; TH
PREPARED IN ACCORDANCE WITH
AMENDEO. WITNESS MY ORIGINAL
REGISTRATION NUMBER AND SEAL
OF ---JAN,---, A.D.. 20_03_.
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SURVEYOR __ y r , -_- �'`�---
REG I STRAT I ON N\ BER \` �
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A�plicanfi
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S�ubci:ivis�ion
�h:�s���S��tio�,�,�LQt r
. �r���or� � er° � �t .
� � System Type (in Ac.�ordance With'Table Va}: .�q
'�d-!IS SVSTEIVi !�S � BEEid f1�STALLE�3 !N C�APtIANCE- �1lVtTH �PLICABL,� N�ta'6'l-I
CAIiOLIIdA GE11fEF�►L STA�'LIT�S, �RtJLES F�3� S�AGE'7'R�T�iE�i' Af1D d�iSPOS�.; .
AND �. COf�1DiTi�PBS _.OF '1'HE IBiAPF2��lE�Ei�T PE�IT �D. �C�idS'�'6aUCT14�Ri �
-AUTHORIZea► Rl.. � � • � . . . .�. ' . .
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. � . �Au ' ed State Agent � • � . � � � . .' .� ' _ ' � Date .
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Installed By- �%I !�• • 'Date: ____ �
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aC..��� ��YO 1�L��'���� �4 �'Li(9�1c� ! ��;� �9 � ' " 7
Ta: Nla¢a �� 3� �arc�! � 2� � SystetYt Type (Ta�ie 1Ia) �
Own��/AQplicarrt S�bdi�is�on �
Adrir�ssJLo�i�n � S�'nas� I�t #
. S��ic �an� n a� ca�on n� nrta at� �
. Stat$ {Dldate � 5 Trenct� V�Jiid#h 3, ft.
Capaciiy. . ga�. � Trencl�. Depth _� in. �•
Tee and Flter � ��� Trench Length 3 ft.
. Baflie � Trenc3� Grade �
Sealant ' Tr+ens� Spacang •
Riser i� applicabte) --� Rocic Depth and Qualiiy
� Tank Ou�et:�Sea� . � � � �am�/Stepdoums �eic. . �
Pe�rnanerrt Marker � . _ .. Pressure Laierals . ---, . .
� � �aanp T�ndc . Hole �Spacing - � -�- . � : . � - . �
. � tate at� � . o e � � .�.,
. . � Ca�aciiy. � . . . � .gai. . . : .. . Pipe Sfeeve . ' � ..
� . . � Waierproof ISeaiar� : � � � � � Tum-upslProtectors � . � . . . .
. . . Ris�r . ' � . � . . Rec;uir� ��c�s: . . . �
Waier Ti hfi . �rom iNells •: - �
Fcar�ap From Property lines . -
. _ �ber.� Vatv�JGate Va�ve : � �-� : S�vctuFeslBasem�t� . � .
. . .: . . Ant�-siphon o e � - � � � � -� �i es rainage ays � - '. .
_ :... �--� i=ioatslSwi�c3��s -: . . ..... . . ... . .: . .. _ . � . _ . - - �SurFace�iNaters � - � .. �
. . . r/' .
� AIarrn� visabde and audibie Pubiic Water Suppiies
Eie�trical Componer�ts Vertfical Cu#s (>2 ft.
Rate gpm � Water Lines 5� �l.
Apq�rnved Pum Modei Vehicle Traffic
BlocX��lnder Pump Ad'acerrt•Systerns ✓' � �
Pump Removal RopelCi�ain.. Easements/Right of Ways
' �Distribca#aon �teen ' �er ,
� Seriai Distribution ' Easeme�rts Recorde�i .
' ressure an I � perdtor o+r�iract
Low� Pressure Pipe • Tri-Par�ate Agre�m��
Appr. PiQe Ma#eriad and. Grade �
Valves • �
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��SE SEE ��.i1��E1) P�iIV FOIt WEg.�. SI'I� ���IJ'�
'Tax �Yap #: � 3 � Parcel # � �- � iownshi�
subdivisio�i: se�ion: Y-o�
�'�e of Wa�r Sai��&�: �Individual Comtnunitp Public
Rec�unrea�en�•
Site Approved bp C`�_ Cs�, � S� d�
Grout�ng Approved byC' -r4�'s �-�"�'3
Well Lo � �Zs-�3
Well Tag
Air Vent �
Hose B� ��
Conc�ete Slab
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Weli Driller: ��� ;��. �
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We111�1ppro�ed. �g: � l� I)ate: ` �'c��'
'�See Attache� Site Sk�ch�
Wells must be 10 feet from propertp lines.
WeIls must be 100 feet from sepiic systeins.
Wells must be at least 25 feet from anp building founda.tion.
Ot3�er conditions-
PC�ID, rev. 09/07/Ol
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�7Cb�7L��7t3��'r'r �7C]L�LO.� ���.��� � � I.:JUUUUt71SJ �rJ � �7 '��
GroutLog
owner: G��r y ,,�,-� ., Tax Map � Parcel #�/Q
I.00at10II: _ H-c A"h S,`1" �`'f0�"'� �� /L�GG✓ �.., �0 0.� L�cA'
Subdivision: Lot
Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from Septic System {Minimum 60 feet)
Total Depth: � ft Yield: � GPM Static Water Level: ,2 � ft
Water Beazing Zones: Depth ���-�``'_" ���� ft ft ft
Casing:
Depth: From � to � ft. Diameter: �_ in
Type: Galvanized Steel ��
Weight: cT7ii kness: ./ gg Height above Grounci:1 � in
Drive Shoe: Yes No Any problems encountered while setting casing? Yes �
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 t/ Depth to Ft.
MaferiaLs Used:
No. Bags Portland cement ��G Weight of 1 Bag _�a Pounds
If mixture (san� gravel, cu ' gs) — Ratio to
ID plates- ��Yes _ No 4 x 4 slab _ Yes _ No
Drilling Log
Location Drawing
From To Formation
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I hereby certify that the above information is conect and that this well was constructed in accorclance with regulations
set forth by the Person County Health Departme .
Signature of Contractor ID# l'% Date (o -2 y-D3
PCHD rev O1/16/02