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APPLICATION FaR SEi�VIC�S
3�-
13" I�aD m:
DBrc�i �: 0�`7 �
1� THE iNFaRMAT1�N I�V T�lE AP9�LlC.4TlOii9 ��OF� �,I� iMPR�VE�1liEi�T PE3aMBT 1S iE'�CDRRE�? �;�+LSiF3�n
CN��G�� OR T�IE �iT� IS ,�,L7��E� iH�i\9 T�iE lfil���OV�iI(iE3e�T P�?aillllT �,�D �iITHOCa12�T'lOi� TtJ
COP+�STF��ICT SFl�1LL BE�Dil�E IEVV/ALID. • ��C` � I
9) �emni$ requested by: (Ownerlageen�lprospeciive awe���j: ��h �E .�u-�� ._ '}�d �e��
Home Phone: a�a �3� t��a Address �� d
BusinessPhone:�Lq q'06 1�3� Nu� �e �?�'l/S. l`/C ?7,�-�� �� a���b�(�
2) �lam� and address ng cvrrQnfr ow�n�P: ��S �� �
f (e� trJ .� `
3) �'roa��ri�j Descriptioaa: Lot size: o`�} Township �� Subdivision:�j 'l�� s�c, Lot #
Directions to the prope►ty (Including road names and numb rs): :�
C�-s�- F�ti. Cl�avl�e lhcr�G R�� ^' � e �r��c �c�
• �— � � _�
3 �e
1�6 u � � rooM
4) �'ro�osed Use and S�ruc�ure � r�: answer each of the following questions: �
a) Proposed � Existing tructure: - � � �Nidth: 3O Depth:�
b) Number or Bedrooms; ber of occupants or people to he served: _'�_ wp r�S�.a �� _
c) Basement: Yes , Plo �, i l e e be plumbing in the basement? P'
d) 6arbage Disposal: Yes , No 1 Be�r'ooM
�) Utlat�r Su�aply Type: Private �(new � or existing�, Public� CommuniiyJ Spring _
Are any wells on adjoining property? Yes_ �lo _ lf yes, please indicate approximate locaiion on the
`, 'siie plan.
o) �oes youa� propeety cantai� ��evi�tasiy id��eiiri�rl jat�sdictiona! we�lan�is?'tes_ i►la�,� hs�" ���
. � G�.c�aw�
PL:�S� t�OT€ THE F�L.�OWING:
� A PI�T 0� T}�E PROP�ia�'Y OR SBT� 3�.�AN MUSi B� SU�iV16Ti'�3� WI� T3-31S A�'P�3�A i 10�1.
r��20P�RTY L1RlES AND CDRi1lE3�S I1flUST $� CL�R�Y MAR4CED. �,
y ii-iE PROPOS�� LOC.4TiOtV OF ,4LL STRUC'iU�Z�S MllST �E STA�C�3] OF� �LAC3G��.
r T�E S1TE �liUST SE R�ADIL� ACC�SSi�LE �'�7� AN �VA�d�IlA7'lUP9 8`t THE HEAI_T}-� ��aAi',.7ME11T
STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-siie sewage disposai
system Tor the above-described property. I agre� that the contents or" this application are �ue and represent the ma; imum
raciliiies to oe piac�d on the property. I understand iT ihe si'te is altered or the intende-d use changes, the permiz shall
became i a '�
� _ � ,2 ���
Cwner ar L�al Represantaiive Da
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� 08 LL 174
��dj. �}y Ucueeo�rded Nop Dy E. 8. Wi
ar aw►,ir� _
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08 12Q-404
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Ta�x M��� � P�:rcel �
S��nc�ilivi�s�ion
Ph�s�e Sectioi� ot r
Applicant: ��� ���,�
Lo ati
i �! rPS: . Y w( . rv
Improveanent Permit
Permit Valid for � Five Years No �zpiration
Type of Facility: g� New � Addition _ Water Supply i� ��
# of Occupants q� # of B, ooms Projected Daily Flow �� g.p.d.
Proposed Wastewa er System: � � iJL°n. `� Type: �
Proposed Repair: C.c �1�E•� Type:
Permit Conditions:
L
Owner or Legal Represe
Authorized State Agent:
� �.ir.!'
�r � �
� . - 7��'I�
� . - r'L�,�i' � �
'The issuance of this permit by`�the Health DeparEment � 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 aze met Thiz
Improvement P.ermit is subject 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 Zaws and
Rules or Sewage Treatment and Disposal Svstems' (ISA NCAC 18A .1900). Neither Person County nor the Environmental Hea�th
Specialist warrants that the septic tank system will continue to function satisfactor�ly in the future or that the water supply will remain
potable.
�r�uthorization to Construct Wastewater System �Required for Building Permit)
* See site plan and additional attachments (_).
Proposed Wastewater System: � �N.U�.�, ��� �
New � Rep�_ x ansio � �
Type of Facility: � .
Type .�1� Wastewater Flow ��� g.p.d.
5oi1 LTA�t: �0`�2 S g.p.d./ ft 2
Basement _ Yes � No
Wastewater System Requirements
Tank Size: Septic Tank: la,�. gal Pump Tank:, `a � gal . Grease Trap: gal
Drainfield: Tota1 Area: ���� sq ft 'Y'otal Length ��O ft Mazimum Trench Depth 1�i in
Trench Width ..S ft Minimum Soil Cover: �_ in Mini.mum Trench Separation: � ft �- C•
Distribution Box
Specifications:
Authorized State Agent: __�
Permit Expuation Date:
ation %� Pressure Manifold
-� � c,� r� l� S1-�.e.Q�'(�.
�
Date: �C— 2 6� o S
The type of system permitted is QC Conventional • Innovative Alternative. I accept_the specifications of
the permit: �..
Owner/Legal Representative: Date:
P /30/2002
Type III (b) System Inspection Checklist
Tax Map 3 Z. Parcel #: 2� � PIN
Owner: - I,�,� ( UcKer Subdivision:
Aiidress: � 30 (' h a r � � e� Nl o� K��1. Ph/Sec/Lot:_
Location:
1)
2)
3)
4)
Establishment
a) type, size and sewage flow in
accordance with permit
Tanks
a) tank risers accessible and surface
water diverted
b) tanks and access manholes structurally
sound, watertight
c) sanitary tee(s) in good working condition
d) tanks pumped, cleaned out as needed
Effluent Dosin$ Svstem
a) effluent appears clear, free of excess solids
b) required pumps present, operating properly
c) high water alarm present, operating
properly
d) floats, pipes, valves, disconnects in good
working condition, operating properly
e) control panel enclosure and components
in good condition, operating properly
fl Drawdown rate:
Ground Asorution Field(s)
a) no evidence of effluent reaching surface
or surface waters
b) surface water being effectively diverted
away from drainfield
c) diversion ditches, swales, tile drains are
well maintained
d) soil cover, vegetation adequate and
maintained as needed
e) protected from traffic and destructive uses
fl disiribution devices in good condition,
worldng properly
g) repair area properly reserved, maintained
h) pressure head properly adjusted
NO Remarks
��
��
[l
[ ] �✓of ct�'ecKe,�
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Summary of Improvements and/or Repairs Needed:
1
Authorized A�en _ Date I� - z2'/o
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ThoMas A.Monk Heirs
P,C, 13-b45
Iron P�pe set at
end of discharge p�pe,
eek
NOTE�Center of creek is property
, line from L-3 to L-13
80 d nall at
Exlst.
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Zeb & Edna Moize
D,B, 126-404
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Tax Map: Parcel #: -
Owner. ` 1�� �-(C �
Date: -2 -o
�.�ne Tap �ap (Sch) Tap �'lo� Line L�ngth �"ilow / �oot -
# �iameter(in) ( m) �'. (ft) ; -
1 ��, Sc� � "7• 1 .
2 2 �� o �
s 2 `' v , ( �
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5 � 2t� (l
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7
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30 �
�� ft of line x 65 gal per 100 ft=°�J��t�c� �s�� ; l0U =� gal
75% x'3�7 ga1= � gal per dose �-� gal per minute (gpm) _�'!ow I�ate
�riction �ead �
I.oss: �ft per 100 ft of supply line x'y �dv ft of supply. line = 100 =~ �7 ft
� ft z 1.2 =_`� ft of fricrion head �.
Manifold Size: 3'� " Force Main Size: 2 " PVC
Total Dyaamic �ead =%�ft of Elevation head� ft of Pressnre head + 2d ft of
Friction Head = �TDH
Pump Itequirement: ��, GPM @ 3�' . ft of Head
Drawdown: �� per dose�i2-gal per inch =�_ inch drawdown per dose
� as �
�����o�n
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11�az No. Taps o$' one side
uce bv lh ibr t3DUin� both ;
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. . . . - . ' �1ow er TaP
Size �Llruerial FZmv G�3�I
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Applicant:
Location:
2
�x M�p i F�rcel
Subcilivision
Pha e Sec ion� ot #
# of Bedraoms
e ti
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. System Type (in Accnrdance UVi�tt� Tabie Va): t b P,,,,,��
THIS SYST�IIA Prfl�S �EEI�I Il�STALLED 1�9 COl�1PLIANCE WIT4i APPLIGA�LE iVOR?H
GAROLlN,�► GENERAL�STATUTES, RULES FOR SEV1fAGE TREATNiE�9T AIVD DISPOSAL, �.
AidD O�LL COf�DiTi�NS OF � THE tIV1PRU1/EiV1ENT PERIVIlT �►P1D COMS � RL]CTiON
AUTHO i'IO�i. � �
. �d��2�0�;
. horizsd State Agent � Date � � ,
Installed By: -)acK �Dezern Date: - �I�ilo� � '
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PCHD, rev. 07/?9/0�
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WELL PERMIT
�'�EASE SE� A1'TACHED P]LAN �OR W�Y.Y.. SIT� LAYOUT
Tax Map �'i'�� Parcel # ��
Applicant: ;���.�,� �
Subdivision:
Location: �
Township:
Lot #
1 1 K V !f� % � I � �C `S f � �.'Y� � \ ���L / � `/�.j�
�� T � ( IJ \
• � `/
�'ype of Water Supply: � Individual
ltequirements:
Site Approved By: ,; ` ���� ���
Grouting Approv,,ed By: � � r � � � �
Well Log: . ''�, �i - E
Pump Tag: �
Well Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab: __
Community Public
Liner:
� Installed by: _
� Depth set: _
Grouted:
Date•
Water Sample::
- � - .! i/ ;
�
- • .. . - � . �.��% �. �T%I L
�-- —
****See Attached 5ite Sketch****
Wells must be la 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:
Date: �(9���'"z'! �
PCHD rev O1/27/04
0�•"Y8�Y007 10:36 AM
`���, S� � .�C" ��r��`3.� �.J��
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�' 1rn.vrns��rara�.�an.��s.:i ��ia��s.�dJin
�'
P�rron Co. Envlronm�nttl H��Ith 336b877808 1/1.
D�O� OD � z �y y
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�'� C J�-i P IA c f�_.! �,..�
� D�1 � �- z �� a�-
Graut Log
Owre�': _� ��� ,� c...� . o Tax Map�,� Parcel #�
Locarion: �' . �,,� ,,1� � �i,�„�_
Subdivisio!�• T�ot #
�Veu Construction
Distance From nea�est t''roperrr Liue ;Minim•,un 10 feetj __ ��t
Dis��ance from Sepric System (Mi;�i�uum 60 feet) ���_
Total Depth:Z� �C' ft Yield: _i,{�� GPM Siatic Water Level: j b ft
',�Jater Bearing Zones: Depth� L RG r'x.�1�� 2?zh ��zs ft
Casing:
Depth: From _�_ to __��� �,/___ ft. Di�meter: � in
Type: Galvanized Steel,�_l
Weight: � 1�1 _ Thiclmess: ,��_ Height above Ground: /£� in .
Drive Shoe: _ Yes No :�ny problems encountered while setting casing3 _Yes �Atv
If "yes" give reason: . ... __ _..___.__..__.r.�... --
Grout: .
Neat: �'aiid/Cenient _ Goncrete GraveUCemene
. Annular Space Width r,� inches Water in Annular Space �es No
Method of Grout: Pumped Pressure Poured Depth to � Ft.
1�laterixLs Used:
Nu. Bags Port!and ccr:�.�nt �_ Weight of 1 Bag �,� Pounds
If mixture (saG ,�avel, cuttiags) — Rario to
ID platcs: �Yes _;do �l x 4 slab " Yes _, No
Llner:
Deptt:: U�►tc Tnstallzd: .�--_
Driill.�Ytl Lo�
From To Formativa •
o � � s���i ��_
, 7 � �y � So �'T c�� ,- 4 �.
- � ��� , �/�.�.� �'..� ...
Grout: Installed by:
Locadon Drawin$
��
i hereby cerrify that the above infermarion is correct and that this well was constructed in accordance with regulations set forth
by the Persc�n Counry Health Department. o �
Stgnature of Contractor� __. ___ ID # Z /3 Z Date � —z .3 --D � �
Pnmp Installment
Pump Installarion Contracwr: State Registration Number:
Pu�rp D�pt�: ft St�ti� R'ater L,eveI:� ft � �
Pump Make & il�iodel: __..____ __�_� _ Pump Size and Ratin�: hp gpm
I heseby certify thai this pump was instalted ann thc well head completed according to the Person County Well Rules in effect `
on this date and that a copy of this record has been provided to the well owner. .