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A32 241._ , Aooiicaticn Da�te: °? °2Q �� �,mounf Paid: 06 • Rec�iot Y: C/p-� � a .�.�5 �,,.�° � � � � �� C�33 oy"7 � �� �_�� �� � ���� �� - � � � ���� E�-�-�.—�a----- ��.��71 3�-3�..9.11��. 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 �CND, ra`:. �612r;02 ,�. � � W �� w 12�Z.31 I� ���,J��' lQ-�` Cj '�p 1✓�- �4��P.�� N/�.. c'�v� ��-. J a� �;d. FsI,� � �' ��` '� �e b�Q j sf ��� —. � ��, ' � � ` e7� (s� � � a� J `�- a _� � M � Z Zp I O �: M ev �'� r � N ,,,.' S ' "{ ,� ' W ��� �,�,Q- `°'' S79'48'04"E m 667.10' ; ;'.; � / ..�v�»va ac rIfy Iftl 08 247–Z19 � — — — �► —' — i tommy Monk � 08 LL 174 ��dj. �}y Ucueeo�rded Nop Dy E. 8. Wi ar aw►,ir� _ 117.38 ac. � , ,/' ,, //, � � .� ;� � S79'S2'38"E �, 1880.75• �// •. ,,, ��e I, J ��r�C� Zeb dc Edna Moise 08 12Q-404 �vf �,��zld� �. �� � ��� 7, 9 � ���� �� '"'^ � � ��� � I���aa-���. ����.IL IL—���.Il�II� 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,� ���� Summary of Improvements and/or Repairs Needed: 1 Authorized A�en _ Date I� - z2'/o _ � .� �- � � ° �� � � � � A � a � � .N � � � : � �� Q � . �o . �� a � -�-� � � a a � fleld � � � � •.�° � '� -397 0 J� Hcn "� - � � . � .� � � H •� A�'� � � . � �� t� � 0 � � � � � � °�y, � � O1 1 �. 0 � .�°� �, � f � � �9i ,a n y A � � C � ,� � � �T � 't± o R j � � . � a � � Z � � � � �+ � .� 3+92.6 I � � � .H L-30.82 c � � .� . 'b �' � �� � � � � � .� o � ,� � a � �� � � � �� .-D ,� .� Ex�: z� �,�� '--� � SCALE IN FEET � � ����s-� ����c��d,Jr°, PLS-�C4�� ��� N��.o��ar �-t,,Ro�bo�o,N�C, �7 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. c�-- - �, 6 n Zeb & Edna Moize D,B, 126-404 � `� � _ J l� � . � � � Thor�as A,Monk He�rs P,C, 13-645 L14 L15 � 'C L16 �� < • � L17 � � � � /� o-,�� ��° �� �� ti _ �� =i� � � , N 1 � i li'``; f / I� , � � � � e 0 � � f � � ��� ������ �► � 1 � �z a�n�.�o���� . : . .. . ��� �� . . � , , . , ,; .' � r •. ' - • • ' ��..: ��,:, � ''' � . � � � x�� � a oos�� � srn�}�t� �',:� . - •��� eti �s a�a ��a : ti .,. �r�� L� •� , _ . ,.:, - � �, . � ': �o �a-�z �z " � '� ..�s.� d �, . ,.. � `��� �' : ... ���� � ��Q .� -� �::� • � . ��g ,'.. _� , :� �oli � i�z=�e�l �� I� ;- . . : t . , �a�a-t,�'z+�g ° '. � (�a�s .$) • • - ' ' ra*z�rrr�eax�a '� >� �.m �a .a� �t�e � �a aaaotia�s �s . �0�x�' x�� � � � , . �u o.t ��u�o � ��a �a ot a�s „tr L •, „A.t ' �'�°� �s �•��a �z ��s��.� �� � �� �a . ,�a� �.t �[ax �s �v �.e� p�t �do • � . . �.� Py'll3 �d0 �'• tuo� d�Z ' ' _ -. a• -. •�,- - t• :- •�.- -';�i, • •� • � _ . ac}�q ' = - .' . '� ' , . . i + .. . ,, . ' • � - . . � . • i�'') a}Mx�uo� �pue'[Kod � - . , . + : t � : , . . . ' •:aeo� sca�y ' . . xuo�J as + u�� ., :.• a�+I=� �i*�J P�P�.L ' u��S d9 ..� • �. .. ` -� �a'J1«i�i3 . .'�P�.tiZ a�i*Aa•S.LT x•�0lLP'�iS �.Li�WS , . ssc� �}ar.�xo� �, � i� S i�Q �� � u°d �}*uZ asaetasd �4 X.ti L � . t�dt°�°� "°[�S Sti 1fphIIii F Y � � '� . . ; i•' �+cr�v� �� �`��. � I�l��.� ��� - -- � � ���� �E�-�s�mm -� ����.11 IE-3L�.�1�� 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 , ( � � 2`' � �i b 5 � 2t� (l S 7 8 9 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 . 1� .. . ,.L .:7 $�ie40PVCTap 11s��Pa�'aP . _. . rt�rw . . �, -- i ' � �. � �cauva�l I�ol1�c4S . ]wi/so�om 9m� � �-� -� a - � - .•"� 1 ; ,. : �[i�)10��0� iiii�iiiiiiiiiiyii�%i�iiiii+iiii i►+���.��� �����N������_����r1���:1 � a v: 11�az No. Taps o$' one side uce bv lh ibr t3DUin� both ; � � � 'h'_' i 3» � � �.� 16 + ,�n 4�' . . . . - . ' �1ow er TaP Size �Llruerial FZmv G�3�I ,�." Sclieri80 .i.� . 1�„ � .S'Ct1P.d 10 %.i ;� :. ����ea ao r� 1 ,, : s�;�� �o �= = :1 � � ���1 �� ���� �� �_. � � � � ���� � ��i.�- � ���. � �. ��.Il. I�-� � �.IL �1�n. Applicant: Location: 2 �x M�p i F�rcel Subcilivision Pha e Sec ion� ot # # of Bedraoms e ti , � A/, " � � !. -, .._I .- 1. L f � � � �� _ L - . 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� � ' � �u�� � j . _ . I r , , ,ti�� - � ` � �� Li—.�= ._n -- ;,.. _ ,�, �..�.._� .,�,--- _ � .� _ . a � . --, � �..:;�.=-�-- ; {� ' - _ F • ,� �. �� � :'t" �� j -' � . � 11� � f�.:_j'i. �, ,�s t�. �� -��� '� ,� .��. : .ti,A :;�,; i� . - ., _.. ; ,;r. I� ._=- ,�v.. .. i� � -, . � �,i;: � v � . �,I,.� i _ � � �y� ���.,�Srcr; _ � , � ' < ( �. i ' .t�:'.sL,;; C� PCHD, rev. 07/?9/0� � Y �� �� ��I�.� �� �y � t. .'.: ...... � �: -��:� ��������',.. . . ..: . :.. - .� ��m.;�-��-��n.�rn�a,�si���.1L : ����.3L-�7La . 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�� . c���Y���" �' 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 ��� �'� 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. .