A32 237. � �e � o,� _ .
� aoo�,cation �ate: Gr 11F-iJ� � '� �• �� / rax IIAac #: Jd 3�
Amcunt Paid: O O � ��
Rec�lot �: � Pazcal #:
�� � ���Y?� � ���� ��
�� - - . ��v'��� �
��..��-.m— — o�.�.a. ���.�� ,.�
� � � �
�►PPl1CATION FOR S6�VICF� � � �- . .
w��v � Ruv �.�n•=• ' octirvmc ua r�+ua+. ,•
' bt�- ,�
. �� � Pennit reque�a hy: �ovimer�entrQros�re owr�e�: o- C� '�i�Ps
Home Phone: 4�9 -�� 5' �� aG / Address: I 3� a� rJ �, c. �- o�.,e �s c�,c� ��
Bt1S�llESS Pftt3(IB: 9/R ��X( �/�'j 8` �in I GP mOh-� AIG �737� �
a" �, ` 3Vc/,13�9 .
2) Name and �clr+ess af current ovvner. ,(��.,;�.-�,� �- r`°��_
. • . . . �Sc 9, r �G..�.Po m�o�,� � .
_f�lm.� !Y'G �7S7S� .
3j Property D�cripl3on: Lci size: /�. � Tawnship: ���Subdivision: Lat# 3
Dlrectians bo the property (lndudin�q road names and numbers): �_
• ih(� /2�� l� la.,�.� �
4� prvQosed Use�t d Structure Description: answer eact� af the foilowing questions:
a) Prapased ✓, Existfig Ty� af Strudur� YYl o c� u_l a � Width: � 3�_ Depth:��
- b) Number of Bedrooms: � Number of �pants or peopie to be served: �
c). . Basemerrt Yes . No � Wiit thers be plumbing in the basement? N/,�
d) 6a�6aQe Disposai: Yes . No ✓ � �
5� Water Su�P1Y Type: Private !�(new `� or e�dsting�. Aubiic� Cammuniiy , S�v�g
Are arry welis on adjoinin9 property`t Yes �No _ tF yes, pi+ease incfic�te approximate I�tiori ort the
•si�e ptan. .
6) Does your praQerty cantai� previousty identiiiad qurisdictionai w�etlands? Yes_ No
PLEASE NOTE THE FaLLDV11MG•
➢ A PLAT OF THE PROPE�TY OR StTE P!_AN N1UST BE SUBMITt'E3] iNlTH THIS A�LICATION.
➢ PROP�tTY LlNES AND CaRNE�tS MUST BE CLFARLY MARl�a: ,
9 THE PROPOSE� LOCATION OF ALL STRUCTURES MUST HE STAl� OR FiAG��.
➢ THE SITE iYIUST 8E READILY ACL'�SSIBLE FaR AN EVALUATION 8Y THE HEALTH DEi�AR7�lAE�1T
S'fJ1F�. . .
i her�by maic+e aQpiir.ation to the Person-Caurrty Heaith De�rar#rnerrt for a s�e e+raluatio� for the on-siie sewage disposai
system for the abov�described proQecty. i agree that the carrterrts af this appii�� are�true and re�res�tf the ma�amum
fac9ifies to be plac� on the property. i undesstand if the s�ie is aiteted or the irrtended use c3�anges, the perrnii shail
became ir�vaiid .
Owner of Legai Repres�rrtaiive
G�- /y�d y
Date
PG;D, tev O6lZT102
�
9B/i1/�008 b9:15 33b59�7�35p PERSbN CQUNT� ENVTRO
l�ppli�cation Da.te: �-� 1-d �'
�Q�s �a�a: r � a. a �
�tec�ipt#: -� D � i c�� _ f 4� 7
� 1...1� S,s'� ��.�.� ��
�Y`�"V � -�. � � �.�'�'`�' �.�'
Jr ��.,�r- , .�..�..:.,R,.,,...�T� �.�,..�. ��..,9x�.,a.d:,.��.
Appii�atioa �ox S�rvic�s
0
r,.
qr
PAGE 51
Tax Map: ,�„�, ,�.
P���� #: �_
tha tvne of
' $IS0,40 ifsirn visitr� . -- �75.40 - ---�T--
Well l�erm it (l�ewlI2eplacement) L] Re�uir o�' �xRxting Sept9c System
�Z25.00/$125_00 No CharQc
��iartuni: X�'the vrfamrat�'�h ir� thY applic,�lian for rtrr �mprnvemeret Pc�m�t is irrcowrrc� faL'sif�d, ar tbe s�te ic al�tr� tl'i�r� 1h
{rrovene,r�t .P�azut an�'rlie dnt6ari^..a�l�'an to Constr�ict s�a� brcar�¢ rr�valid
i) Service5 �tequ�ea�te� b .
Name: �1�, � �• ,rn.�� � Phane � (I�o,me): ��b-� � �l¢ �.��
Address� G w- � „�. .� �Qr�, i.�. �, (work/4n!!):
� � c "3 �'1 ---�-
2)Nat�a aud auddress a�'eurrent owner (if d��'er�at tban ap�Gcaut);
N�arrie; Yh-�,.1 j 1'Li,e� :� �,a M �4rrJ ts w�
Acldress: �
� �� nti� i.l C
3) riroperty Descri�tior�; iot 5i�; i � 5ubdivision:
Address aud/or direcrians ta pronerr,,: f.�. r.�� �L��..
� �t
4) Px•oposcd �'�e and �jrp� o£S�ructur,e:
��d��Y �,�� Busines�/'I'yge: Qthar
Number of bedroams —�.— / IVumber of pnople serr«d (sea�ks/emplo�yeas):�
�asemen�: Yes ^, No (�vyth plurnbing: ��s ,� No G�ubaga dispasal: 'Y�� No
Appro�ir�.ate �ize of bualdi�g fouuudat�on: �e�gfh�'Widt� - �� ^.. �
� Wataer Sup�ly:/�
�rirrate W�I1 ✓ (proposed �xisting,_„�,,,,)
COmmun�i�r''WE�1: �_ Pvbiic Water Sy5'lc�;
�A,re tkere we11s vn th� acijoi;ning psopertii�s? No Yes {p�� sho�uv location �n site p���
N'ot.,�„ �„�,.' A,� com�t��d rp,plic�rtinn �n�rst a�so irtcir�r��: �
➢ A placr/site plan �fthe property that s�rows proper�y drlaaens�'ans and zke saze arrd l�,cati�n �f a!!'
prvppsetd sr'rucir,�e,�
� A si�ned copy of t/ae `�,01 }ti'r�pr�ratdan'form venEf'yin$ t1:a�'t�e,praperty rs r�ut� to b� �vt�lrra�erl,
Y am s�bmittrn� ehis sp�lir.�ion to requ�st servi�ces ixom� tbte �'erson Coa�►ty HoaIt1� l'a��a�en� T�o int'ormatiab
N�'o'�Ydtid i� secur�t+�. Z u�ddrsta�ud t�t�t�t if �upy aite r"s sI'Cered or tbe i�xCeLded use ebattgcs, alI pertuit� s��� becopp�e
i�ptr�alGd. .
Sign�tare (Owner/Z,egal .R�►resentah'�)�%�°�'"5 �,� , ,,. Aatc+: g" i i' ��
��
1 1107 Persnn County Environzn�ntal kIea)th. 32S S. Margart $�, $uite C� Roxt�ora, NC �7573 (33G.597�1790)
; ON THE
CLOCK __M
.INEY HAWKINS, JR.
JD OTHERS
184, P. 616
IF
PART OF
ADA HAWKINS
HEIRS
P.C. 12, P. 18
ADA HAWKINS
HEIRS
D.B. 313, P. 23
N�g os3�
�1,�.� ��, �� I'i � ►-�
►,, -- � � o ,
MICHAEL W. EVANS
D.B. 316, P. 559
P.C. 12, P. 391
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IF CORNER ,
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6^ LARRY EUGENE MURRAY
� o '_��\ CONSTANCE PRINCE MURRA
� • � D.B. 415, P. 400
� �' \� P.C. 13, P. 244
NG 50' � �
:ASEMENT � �
, P. 391 � �
, P. 514 \ \
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Applicant: ( ,, h�.�, NeoS�t-,
Location: N,,,.�10 !►��I (s H.cx� �
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n��l I.S �
23 7
T;��x f1�1��-��E� � Parcel # - — —
/
S�uhciivi�s�ion �
Pfa��•se SecGiom Lo# � /
�
Improvement Permit
Permit Valid for X Five Years No Eapiration
Type of Facility: New 3C Addition Water Supply �i,�� .
# of Occupants �_ # of B ooms Projected Daily Flow 3(�C� g.p.d.
Pror�sed Wastewater System: � �ti � . Type �2
Proposed Repair: �o.�� Ca5 %, ��,.�, � Type:
. T _ �
Permit Conditions:
Owner or Legal Represe
Authorized State Agent:
Date: � 7�� /
Date: $-1��/
The issuance of this permit by the Health Department i� does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met This
Improvement Permit is subject to revocation i# 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
Rule�vr Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person Connty nor the Environmental Health
Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply w�71 remain
potable.
Authorization to Construct Wastewater. System �Reqnired for Building Permit)
* See site plan and addi#onal attachments (_).
Proposed Wastewater System: ��von��
New �C R air Ex ansion
Type of Facility: � ��
Type�. Wastewater Flow �.p.d.
Soil LTAR: � a75 g.p.d./ ft 2
Basement Yes X No
�astewater System Requirements
Tank Size: Septic Tank: l�Z gal Pump Tank: '— gal Grease Trap: — gal
Drainfield: Tota1 Area: l� sq ft Total Length �-/'N� ft Ma�mum Trench Depth /� o'� in
Trench Width �_ ft Minimum Soil Cover: Lo in Minimum Trench Separation: 9 ft
Distribution: �C Distribution Box Serial Distnbution Pressure Manifold
Snecifi�afinnc_ �(LY��r�� , OL`bQ �CJfl('4�S /71i� ('.o��i-i1� ,s 1 Ul �1�1�7i�n rt OI S�G�,
Authorized State Agent: �
Permit Expu�ation Date:
Date: �'-� -�(
The type of system permitted is � Conventional Innovative Alternative. I acce t the specifications of
the permit� p. `b(�
Owner/Legal Representative: � Date: d 7/ J
PCHD7/30/2002
. : ���� 1'� . ���� `�l �7
1 �^
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�aa��.ai�o��s,.�.-�8��.�• ��a.�'��ia
S�T�.. ��E.T -L'I�
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- �-
•_ . , �•��e`i•_•-:
r�� ■ -� ' . - �
Tag Ma.p #� 3 a Parcel #�
Section/Lot# � c3
�-�=oy
. Date . : . �
sy� �o� „�„�� �m����u� �y. The contractor must, flag the system prio �..
be the installation to imsure tliat pm�iergmde is »urintazned � ,
. �'
ab9oc '� 1� •
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��ra.vra�r-��nn�n.��.�.�.� ���.�n.���ia
Applicant:
Location:
T�x M�p / Parcel # -
sU�b�t,���5�0�, :. .
Ph�s�e Sect+ion Lot #
# of Bedrooms
Operation Perm it
System Type (In Accordance With Tabie Va): �
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTIOP!
AUTHOR Z T10N.
�� �v-ei IO -1-0 �
Authorized State Agent Date
Installed By: �` � 1��� 'e., Date: /�"('b �
:
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1t_.i�'�"i7L'{C7'�^i� ,�rv11 a�31'�.'�.� JL 1L��.11�3�A.
�u��s���a� Ada�a�on�/ l�o�i�e �offie ���lac��e��
Tax 1VIap #: �� Parc�l#:�_
Approval Requesterl for: � Mobile Home Replacement 3�1e Slw � 3�1� pl�
� Building Addition
Applicant
Address:
Phone #'s:
Permit Located: � Yes No
Installation Daze: - 1- 0 Desi� flow: 3�(gpd)
Current Contract with Certified Operator on file (if required): - ��
Water Supply: '� Well Public or Community
Wastewater system shows no visual evidence of failure on: � 1 Z �� -{date)
� (ApplicanYs signature if site visit is not required)
nts: -Q 0 Sr2 D r/�?N'! � �TI Q' �( Qr�'S .o'! -
i C S(.. C �-, Q'.� C� n.,; v, . F� 1 [ �
: � �s�ditio�tep➢ac����t App���e�
� W�r $� lZ D
Environmental Health Specialist Date
`� 11/l�/OS
�
Tax Map
Applicant: �
Subdivision: �c��t'�
.
. .
:�1�����. ������ :
.:�, �
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:: ::: ..
�' sa�u.�m�„-,.,.�,.-„ ��$�:� ��m�.��n.:.
WELL PERNIIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
d23 7
/�3 � Parcel # � Townslup: �%i�,Qn I%'1.<«�
Type of Water Supply: v Individual
Requirements:
Site Approved By: �5 `1-ZZ ~o�y
Grouting Approved By: �15 a -Z2-b�{
WellLog: �1j �'-2,2-0`�
Pump Tag: �
Well Tag: CS
Air Vent• t � - ��-�y
Hose Bib: GS
Casing Height: �5 .
Concrete Slab: C�S
Community Public
Liner:
�Installed by: �
Depth set•
Grouted•
Date:
Water Sample:
Well Driller: 1�
Well Approved b �
****See Attached Site Sketch****
Wells must be 10 feet from property lin
W lls must be 100 feet from septic syst
,�lls must be at leastJ,.2i�eet from any building foundation.
�
Other conditions: L�� 1� ��2- c�c-Q�c�.
Date: it- t t��
PCHD rev Ol/27/04
BarnetYe Well Drilling Inc 336 598 9275 09/22/04 04:50P P.002
� �� .S � ���� �� Dr�� aD � �
.`�-� � - - � �� �
- c� � ��r°�� �,�ry,�ry�,�,�} � _a� �
�' aurs��uu-�v+�a�� �ra�r.a.zG�n.��• ¢��m�+L•••� lXNlSL� I:NWlri�R!
, I Grout Log " "L'3 �
Owncr• r�n�,� F�-E _ Tax Map �� Parcel t� �'
LoCatzan:
Subdivision:
Lot #
„ We�l Constrac#ion
Distance From nearest Property Lit�e (Minimum 10 feet) lC�
Distance from S tic System (Minimurn 60 feet) , ��
Total Dtpth: �' , ft Yield: GPM Static Water Y,evel: ��� ft
Water �earing Zones: Depth ? ft� ft� ft ft
Casing: �
Depth: Fro�nn � to ft. J?iameter: �_ in
Type: Galvar►ized Steel . �/�
Weigh� '�'hiolrness: �� Height above Ground: � in�
Driv'c Shoe: "Yes No Any p;roblems encountered while setting casing? Yes .� No
Yf "yes" give reason:
Grout: '
Neat: SantUCtcnCnt Concrete GraveUCement �
. A,nnular Space Width inches Water in AnnuYar Spflce Yes No
IvZethod of Grout: Pumped Pressure Poured .r Depth �, to �b �t.
Materisls Uscd:
No. Bags Portla�nd cement � Weight of i Bag Pounds
If mixturc (sand, gravel, cuttings) – Ratiu to
�D plates: ^,�'Stes _ No 4 x 4 slab ,� Yes �, No
Liner: .
�ep�; Date �lled: Grout: Installed by:
Drilling Y.,og
Lacation Drawing
�.� � � ��,���
rr �...,•!�__,� '
��� �,1�.—,.,.
�, � %S'�r ''"~` -
_ �`�� � � �
�
-
■
I hereby certify that thC above
by the Person County I�S.er��
Signature of
that tl�is well was constcuoted in accordaz►ce with regulations set forth
YD # Q� Date �- c� � 'O�i
�"- Pum�p Iust�lment
Pump InstalIation Co�tractar: Statc Itogis�atidn Number: �C�a�{
Ptunp Depth: �4 ft Statie Water Level: 5 ft
Pump Make & Model: PumP Size and Rating: � a hp �� gpm
I h�reby ccrt�i�y that this pump was iz�stalled and the we head complcted according to the Person Cour�ty Woll Rules in eff.'ect
on this datc and that a capy of this rccord has bee ded to t�ie well owner. .
Pumu InstalIcr S' �"�' � Date• �`�°� ��� PCF�77 rev 01/27/04