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A33 40�„ t � .:. . The District Health Department CASWELL - CHATHAM - LEE - PERSON COUNTIES Water Supply and Sewage Disposol IMPROVEME 3 PERMIT Np. • Date — � • Owner: `� f � Location: .' %'� ��-✓�;��--- Contractor: �� y� Water Supplp: Pnvate � �blic �� �� `� --L-i � 6,� ��. Sewaqe Disposal Facililies: No. bedrooms � Dishwasher, Disposal, • washing machine, other automatic appliances Size oi tank: �' ��;L Nitriflcation line: � i�; , 't . Other disposal facility: Water supply and sewage disposal facilities location, installation and protection must meet state and local regulations. Septic tank should be pumped out every 3 to 5 years and shall be main- tained by owner in such a manner as not to create a public health hazard. Septic tank and nitrification line MUST BE INSPECTED AND AP- PROVEB BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT STAFF BEFORE ANY PORTION OF THE Il'�STALk>AT I�Jr IS COV- ERED AND PUT INTO USE. f % r� r��i � Date approved: Well: Sewage Disposal: Counter�� � �Qy� aigned �` By: (Owner or his representative) Certi�icafa of Comple2ion �� -- Date Approved: � By� San' �an (OVEB) Location of well and sewage disposal iacilities aketched on back. NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water supplie� etc. Note special problems existing on lot. Write in measurements in order that installations may be located � at later date. No ocation of water supplies on adjacent lots. (1) - ,( �"�,"+i�'� � 2 Iv - t,_-. ��.--'- �, _ ( ) '� _ � ?��.-1 I J_ 1 I I I I l_�.__1�.. ���'�■ �- I I I I,1-- �� -�� ��- �'� --'���� ---� �� � � ,- . � H O � � Improvements Permit. (F,stablishedlRecorded Lot) Impxovements Permit (Unrecorded Lot) �-�4-�'7 lt SERVXCES �. . , ��.; j�,�.'S �t< y,s�.g �`�'�s"xs ah�'�*�`,+��'k„T�::e�.$�,�Si � y�re�:, � '�1�� �°"�t� �� ����s�.� � y� ° �8s '�� � : �� £a� . ¢ : A-• Reinspection of Existing System (Loan Closing) _ Repair/Replace existing Septic System �provements Permit (Mobile Home Replace) �._ Permit for New Well Improvements Permit (Addition) _ Replace Existing Well 1. Permit requested by: . _. 7. Dimensions or Proposed Structure: owner/prospective owner/agent: - Width: l� X,`. Address: W���� aM ���` o - Depth: _ � w U � a W � z ome Phone #: �9'7- S� `� 4 usiness Phone #: - Name and address of:current owner: Description: I,ot size: Tax Map#: .•� � � Parcel#: � � Township: � � N � � �;.(-� a� . Directions to property: ames,�tc. ��_�3a3 Number of occupants or � Road # & Road le to be served: 8. What type (if any, additions, expansions, or replacement is anticipated to the structure or facility . that this sewage disposal system is intended to serve? 9. Water su ly tSpe: private public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No p. If so, identify location: 10. Type of structure/facility: Proposed�Existing: Q Type of dwelling: ,,,_� House: ❑ Mobile Home: Idl3usiness: ❑ Type of business: Number of Employees: Number of bedrooms: � � Garbage Dispos�al? es No [' Basement? Yes1iJ I�ofl If so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the PerS0I1 COunty HCalth Department for a site evaluation for the on-site sewage disposal system for the above described property. I agree 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 intended use changes, the permit shal! become invalid. I understand that before an Improvements Permit can be issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of the site by the Health Dept., this application shall become void and all fees paid forfeited. 2t.___� Si-ncc� Owner or Authorized Agent Permit Issued ❑ Permit Denied ❑ Plat Observed ❑ Signature _ r' Date ' 1' �R J� K xY �. � f F1�CI'ORS-SIiE �ALUATI4N, z: s si �..: £�ARF,li 1'y x x`.. ,. �.> x.��2 :.:� �, r.� iAREh� c s, i: z c { k: .< <a .:>z.r. ....,..<£ . .,.:.., ,.�,.,... ��..: ..... .. . _ �. , 1�RFa , �: x ..'r. 1. SLAPE (%) S S S S PS PS PS PS V U U U 2 SOII.TF�C7URE(I2-361N.) S S S S (SANDY, LOAMY. C1.AYEY. N07E 2:1 CLA� PS PS PS PS U U U U 3. SOiL STRUCiS1RE (12•161N.) S S S' S (MYEY SOII_S) PS PS PS PS U U U V d. SOILDEP[}{(W.) S S S S PS PS PS PS U U U U 3. RES'IRICI7VE HORIZONS (iN.) S S S S (1MPERVIOUS STRATA, ROCK) PS PS PS PS u v v u 6. SOILDRAINAG&GROUNDWATER S S S S (DCCQtM/1I„k INTERNpW PS PS PS PS V U U U 7. SOII.PERMF�IBIISfY S S S S (PFRCOIAATION RA'fE� PS PS PS PS U U U U E. AVAILABLESPACE S S S S. PS PS PS PS V U U U 9. S17ECLASSiFICATION(SEEBELOW) SO1L SIItIES " S•SNTA6LE PSPROVISIONALLYSUITADI,E U•UNSUfTABLE RECOMMENDATIONS/COMMENTS : STTE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, f 11 areas, wells, water bodies, slo-e patterns� CtC.� C:NMfPR01DOCSIAPPSEC.SM FINANCE.PC � � a w � a M �1 � B 1577 PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERNIIT Not for waste water system construction. No permit(s) for Construction Location or Relocation Activity shall be issued until Authorization for waste water system construction has been issued. Tax Map # � 3.� Parcel # �(� Zoning Township "n Owner/Contractor �r 1,'� ,�•� /� ►�� d sl, P✓ Da 3-� y' - q r7 __ Location/Address Subdivision Name �.r�s �, iz�, Lot# �'���.,�v; c.t. ��J SEWAGE SYSTEM SPECIFICATIOliiS Repair Lot Area /, 2� cr �s Size of Tank � ���� � SFD Mobile Home t/� Size of Pump Tank `' Business # of Bedrooms�_ Ntrification Line �' �" W � � ,�, Max Depth Trenches �� Permits may be voided if site is altered or Well and Septic Layout by Comments: Date � � c Installed by ' ' ' Approved b� Well Permit Paed ❑ WELL SYSTEM SPECIFICATION� Comments: Sen Repl Installed by, Required Air V t uired Well Lo ell Tag Approved by This'report is based in part on inforination provided the homeowner or his/her representative in the application submitted for this permit. The environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health specialist is also not responsible for concealed conditions on the property or for statements in this � report that may have resulted from false or misle�ding statements provided to him in the application. Neither Person County nor the eavironmental health specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:\amipro\permit.sam O1/95 rev.l.l AQolication Date: $'� '03 Amount Paid• ��UU Receipt #• 2 7A � L Tax IAaA #: �1 3 � � �arcef #: `( . � �� � ����;�� ���� �� 3 = --� � � �TZ�T'1L� �Y � s�waa-�s as----�- .a aa�.71 7E—�L � .�.ZL�l�a APPLICATIOIV FOR SERVICES 1) Permit requested by: (Owner/agent/prospective owner): s�-�� C�-.�o � l S' ���`" 10 � f'� o M, �$ Home P hon e; S Z �/ 3 - � 2 �{ S A d d r e s s: ' � i o S .�. � e. l� �2e Business Phane: f �l 8 L! S� 3 F-4 e� n. R� �j n� NG �-? S3 2) iVame and address of.current owner: lN l��� a M t� 2� �S� C'/� { ^esuS tiv�-C � 12C}� . .. 5P�,n�+� ;v„ a���t3 � 3) Pro�serty Descri�tion: Lot size: . O Z Township: �� �ni ���bdi ision: N��f� Lot #�l1 Direetions to the property+(Includi�g road names and numbers): C�v �, � �� p,� L_Q -�- c� '!h e �� � s o. s s� � � C h � l � ° '�-o °f- a r� 4) Proposed Use and St re escr� '• answer each of the follo�ing questions r�� a) Proposed t� sting _, Typ tr c re: ne� 1� � e �U�r!l P-. Width: 2.7 . Depth: b) Number of Bedr oms: ��2 �� rgb�rj occupants or people�to be served: 7 c) Basement: Ye , No � Wi��aert3 be pl mbing in ttie basement? d) Garbage Disp al: Yes � No C� � 5) Water Supply Type: rivate �(ne or existing�, Public . Community . Spring _ . Are any wel s ining property? Yes No _ If yes, please indicate approximate location on the � site plan. � . 6) Does your property contain previously identifled jurisdictional wetlands? Yes_ (do� . PLEASE FIOTE THE FOLLOWtP1G: ➢ A PLAT OF THE PROPERTY OR 51TE PL.AN MUST BE SUBMITTED WITH THIS APPLICATION. ➢� PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARI�D. ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE. STA►!�D OR FLAGGED. ➢ THE SiTE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF. I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for. the abov cribed prop rty. agree that the contents�of this application are true and represent the maximum facilities to be plac o theh.}i-o%�y. und�tand ifi th�site is altered or the intended use changes, tfie permit shall become invalid. � / / � /'J / % or � - ��- D D^atB PCHD, rev. 06I27/02 . s���� );�� ������ �� ' � '����� 1E.��.���-����.]i 1E-�T��Il� � S�. §��.��' . N �� i l I i a r� � l'ads � c r Tas Ma� #� 33 PaYcel � 4 O , _. � � � Section/Lor# � R a4 -03 ; P�uthoriaed Stat� .Agent � � . ' Date � . . .Syst�t c�osrs�ones�s aae�s�s�t ����ssrs �►. T"�te � a�st„� �e s,�tst�a� ta,. ' g � ��rs �o sarrasr�a �t.�s+n�'gs� as sr8a�aiated �� . � . , \ � . �� _� - p.�c� �����f �sti��� u.S���'��-�� , ((''` �, � t 1 I,, c. �✓�F�(� �(C� �, d �,� G�LQ' �� Sca.I� �. � ��= s�. \ \ \ Wou` �' � n� D�M K-�` �OUSL MD� 1 n� .� �a S �o(lr��(� � C.� �µ( EQh�� � i �. �� �o�� ��� �� P y d4^� �c�K-s r 5 � Maf^��� � 5p��'�0"�'�- s � P.�ic,. . ��uc' DD �°� c(o5`� �9µs� �,p, �o �„a� . W�tl� � � ��( .. �� �9J�/4� �' � ���� . J � ���� ����� _ . . ,� � � ���� � ��a� � �„-,�-�. ����.IL �-�-� � �.Il �I�. Tax Map #_� Parcel # 1 � Existing Sewage System Report For: +� Mobile Home Replacement Addition Type: � �j, .5cott �rrall Requester: ���� � a M vr�d'S�� r Home Phone# 2-5 Z 431- �1 o"Z9'� ���'LQ E��.tS(�S CG�urc.G� �Z c�� Business #�to(n �3p�� g'S3� .S c.n� o ra , Iv G o`Z 13 �'3 _ �cc's �M i i l 1Zoc�� �ox � [ t�4(� C'.�� r�C� �.��d Original Permit Located: �S Water Supply: � h� � r( <<<� Septic System Designed For: V Residential Business Other # Bedrooms � # Employees Other . � System Type: (� 1%Cf1`�! (7 �►Gi ( Tank Size: �u << Nitrification Line: K 3 Date Installed: �_ s� �, Certified Operator Required: f�' � On-site wastewater disposal system shows no visual signs of malfunction on � aq�� Permission is granted to: ���P �a�� a 6 r 5tam � 1,��� Gt, a 6� ��n'1 �i. Comments• J c� c� �t, S k�.�l-(� � ��. � � �-� O . � Gt Lti�%�� ` �t,0 Environmental Health Specialist • y- ��-� -, � Date• � ��� ���.�� ���.� �� `---- � � � ����- ��.�.���, ���.�.� ���.��� _ ����� ���� 5���.��� �������.5����� '��x idYap #: �_ Pa�c�i # �'� 'g'ownsh�p �J" C>!►'1D r� �Plicaaa� � � � ( i t�.m � r� S � Sulbdivasion: Se�tion: �.o� �. �+. r �• �� Wat�r v Individual Con1m � Public_ �'�e of S� �: �tY ��s�.ig�effiemm�. . Site Approved by , / Gsouting A�jS=o�ed bp '�" ��� 7 �ell Log � Well T� Air Vent ✓ I�ose Bib 1/ Concrete Slab We�1 I�siffi�r. 1-��i' � � � �ell Approved ��: I�ate• � �� �Q � , �°5ee 1�ttac��si Sit� Sk�#ch� ' . . Wells must be 10 feet from propertp lines. Wells must be 100 feet fram septic systems. � �ells must be at least 25 feet from anp bus�ding foundation. Other conditions- �( � l7l,J � L�,`� f"'� V i� Ca � n 5� �- 5 Kc��c�� PQ-�, rev. 09/07/Ol FR�M : -�.--- FAX N0. : �� l : r / �� � � ll 1i `� `i+ "� � �' � � ���� � �wi�u-���a�x�d:.�o.1 iE�,��n.1�.�-a. Qwner: _ Locatian: L�= � �� Subdivision: Feb. 25 2004 05:19PM P1 , r� c r I 8, .—�����/� om�, ny r: �e r� 1.1_ �.., � / � p��te fJrili�cf � Grout Log - ,., Tax Map �,� Psrcel # �(' Well Co sCrytctiot� Distar�ce Fram n�arest Property Line (Minimum I4 feet) pistance fro�'n Septic System (Miz�mum 50 feet} �,^ ,,, Total Depth: ��,�, ft Yield: �_ GP?v1 Static �ater� ?.e� .�.�,� ft VJater Bea�ing Z�nes: Depth � ft.�� �-. 3 S�/� e'! G�r�" � c���: �. � y Depth: From ,�.r: s to ft. Diameter: � 'iypa: Caiv�niz,ed Ste�l � � � Wcigh� __ Thialaiess: � Iieight above Grouad: % 5 -� D r ive S h o e: ��� ,_.^ �� �Y prablems �ncounier�d while setting casing? Yes � I�ia �f "yas" give reason: G�rout: GraveUCement._.� Neat: �_ S�uud/Cement C�� ,.�- • Annular Space Width r1 tnches Water ia Anaular SFgce � Yes �,,,_. No t• ��r PTOS5llTe PQliTed ��,St� ,� tn .,—»-- ��' Metjwd af �'xrau . i�pe Materia�s Usat�: . � F4�� Na, Bags Port?�ud cement �� ��ight of 1 Bag �_ If mixture (san�, g�avel, cuttixlgs) - Rat�o m �U plates: � Yes _, No . 4 x 4 slab ,�, Yes ,� No �.iner: Depth: Date Insta.11��: � Grout: �,,,_ Inst�ailed by: 13rilling �.og �ocat�on Dr�twing I hereby certify that the above information :s coneci $nd th�t this welI was constructed in accbrdartce wit�'� re8vlations set fortt by the Person County Fiealth Department, Signabnre of ppmp Insts�lrnent Date � ����6 `� pcunp Ins�lation Contr�ctor: State ite�s�atian �Tumiser• _. — �p ��, r� Static y4'ater Levei: ft Pump Make &?�+f ocie�: Pump Sixe and Rating: �P _..�.- �'m I hereb cercify that �his pump was :nszlled and the well r.ead complered. accord'mg io the Person Cou�ty ��eU ftules in ef�e�c Y on this da� a�.d that a copy of this rtcoxd has be�a �rovid�d to t�he vvell ow�ler.