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Tax Map;#: �33
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� APPtlC1kT10N FOR� SERIRIC�S -
SHALL BECOME INVALlD. �
1) Permit requested by: (Owner/agent/prospective owner�: � a✓ i(� C�°'�►'� Se
Home Phone: 33 (o � 5� ?" �1Y i� Address: 8 o LO t. �. r� '� ✓'�-
Business Phone: '�5 ?� 6-�9 �9- �?� � 0 dx '' L%'T �
2) Idame and address of carrent owner. o��i c� C. o��+�+ C' o� N� ��� �u ��'�-
C. OC_L� r� v •
%ZoX�orp � C.� �Z7�%�
*,�rs �/ �-- L
3� Property Description: Lot size: 7.? 3 Tawnship: 1r�0 � a idq��Subdivisian:
Directions to the property (inciuding road�ames and numbers): ��+� �_ LaK� : �oa, `�
_2rnr jrJ D �-► %�F. �
4) Proposed Use agd Sgructure Description: answer eact�of the following questions:
a) Proposed ✓ Ex�ting Type of Strudure: b����i C�G Width:C�� Depth: �- 8
b) Number of Bedrooms: �ji' Numhe� of occupants or peopie fio be served: ,
c) Basemen� Yes _, No W�lill there be plumbing in the basemenn
d) Garbage Disposat Yes � No �/"
5� Watsr Supp(y Type: Private ✓new ✓ar existing �. Public_, Community _, Spring ,_
Are any wells on adjcining property? Yes _ No�ff yes* Please indicate appra�dmate location on the siie plan.
6) Does the property cantain previously identifled jurisdictionai wetfands? Yes _ No ,,�
PLEASE NOTE TNE FOLLOWING:
'➢ A PLAT OF THE PROPE32TY OR SITE PLAN fiAUST BE SUBAai'TTED WITH THIS APPLlCAT10N.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARI�D.
➢ THE PROPOSED LOCAT70N OF ALL STRUCTURES MUST BE STAKED OR ELAGGED. �
9 THE SRE MUST BE READILY ACCESSIBLE FOR AN EYALUATI�N BY THE HEALTH DEPART�AEAIT STAF�.
I� herefiy make application to the Person County Heaith Department for. a site evaluation far the on-siie sewage disposal
systern for the above-descnbed property. I agree that the contents of this application are true and represent the ma�dmum
faali�es ta he placed on the properiy. 1 understand ifi the site is aite�ed or the intended use changes, the permit shail
became iuvalid. � _ ,-�
Owner or Legal
l � �- �d a �--
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PC�fD, rev.10M7101
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Applicant: �.��
Permit Valid for Five Years
Type of Facility: � �p �
# of Occupants # of c
Proposed Wastewater System: �j
Proposed Repair: �pz ," vp,v�,��
Ta�x MaC� � Parc�el # �
S�ihciivi.s�ion
Ph��se Sec�t�ion Lot +
Improvement Permit
No Ezpiration � /
��- New .�/ Addition _ Water Supply V✓����
s Projected Daily Flow ��D g.p.d, .
��� Type: ��'
TYPe� �
Pemut Conditions: �Q� �,`� S't�� h
Owner or Legal Represe
Authorized State Agent:
Date:
Date: � —( 2 � 2
The issuance of this permit by the Health Department in does not guarantee the issuance of other perniits. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement PermIt 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 permflt was issued in compliance with the provislons of the North Carollna `Laws and
Rules for SeivaPe Treahnent and Disposal S stems' (15A NCAC 18A .1900).
�% Authorization to Construct Wastewater System �Required for Building Permit)
* See site plan and additional attachments (,_�.
Proposed astewater System:S�v�,�,-�i tYLq,
New Repair Expansi n
Type of Facility: q�,�� Q
Tanlc Size: Septic Tank: (a cv gal
Drainfield: Total Area: �d� sq ft
Type`�� Wastewater Flow�.�� g.p,d.
soil LT�x: .� 7� g.p.a.i ft a
Basement Yes No
Wastewater System Requirements
Pump Tank: gal Grease Trap: � gal
Total Length 3c9 � ft Maxunum Trench Depth o�� in' '
Minimum Soil Cover: � in Minimum Trench Separarion: �_ f}
Distribution: Distribution Box ✓ Serial Distribution Pressure Manifold
Specifications: � �' f --� St����
Authorized State Agent: �
Permit Expiration Date:
� o -
0
The type of system permitted is �Conventional
the permit.
Owner/Legal Representative:
..�...,._. .� -
Date: �`-�.�-��
Innovative Alternative. I accept the specifications of
Date:
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WELL PERMIT
PI.EASE SEE A"a"TACHED PY.AN FOR WELL SITE LAYOUT
Tax Map #: Parcel # Township
Applicant 1i''i C�
Subdivision: ` Section: LoL•
I.ocation:
T e of Water Su �/ Individual Communitp Public
Rec�uirements•
Site Approved by
Grouting Approved bp
Well Log
Well Tag;
Air Vent �
Hose Bib
Concrete Slab
Well Dri11er.
Well Approved By: Date:
'�°5ee Attached Site Sketch'�
Welis must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from anp building foundation.
Other conditions: -
PCi-ID, rev. 09/07/Ol
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SITE. S�TCH
Name �� � R�'►�t. C Tag lYlap # �� Parcel #��
Sub ' ' n � Secti.on/Lo #�
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Authorized Sta.te �t � Date . �
Sysfem co»sponents represent ap�iroximate�contours only. The coniractor must, flag the system j�rior to
beginning the installation to insure that pm, pergrade is maintained ��
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• Appiication Date.
Amount �aid: d
RecEipt #:
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�aa_��ia-�aa�+-�-� .e�-�a.I1 IF--��mIL�ILa
APPLlCAT10P1 FOR SERVIC�S
Tax flllap #:
�- �3 3 �
Parcal #: •b �
IF THE INFORflAATI�N IN iFiE APPl:1CATIOiV FOR AN IMPROyEMEPIT PEFt11AIT IS INCORRECT, FALSIFIED.
CHANGED OR THE SITE IS ALT�RED. THEiV THE 1MPR�VEiIAENT PERMIT AND AUTiiORIZ�►TlOtd TO
CONSTRUCT SHALL BE�OME INVALlD. �
'1) Permit requested by: (Owner/agerrt/prospective owner): ��D �o'� � r.
Hame Phone: S'�j9— 8G � 3 Address: S� s
Business Phone: 5,�.�so..� /1!G . � 7� �.3'
2) iVame and address of current owner.
3) Property �escription: Lot size: �7� � Township: S bdivision: Lot #
Directions to the prope (lncluding road names and num ers): ' '�,
C : e a.ee .t7���.
/ .
4) Proposed Use and Structure Description: answer each of the foilowing questions:
a) Proposed , Existing , Type of Structure: Width: Depth:
b) Number of Bedrooms: Number of occupants or people to be� served: -
c) Basement: Yes , No Will there be plumbing in the�basement?
d) 6arbage Disposal: Yes No _
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5) Water Supply Type: Private �(new _ or existing�, Pubiic , Community� , Spring _
Are any welis on adjoining property? Yes_ No � yes, please indicate approximate location on the
� site pian.
6) Does your property contain_previously identified jurisdictional wetlands? Yes_ No �
�
PLEASE NOTE THE FOLLOIMNG:
9 A PLAT OF THE PROPEl2TY OR S1TE PLd�►N MUST SE SUBMITTED NNITH THIS APPLlCAT10N.
9 PROPERTY LINES AND CORIdERS MUST BE CLEARLY MARKED. ,
9 THE PROPOSED LflCAT10N OF ALL STRUCTURES MUST BE STA�CED OR FLAGGED.
9 THE SITE MUST BE 4iEADILY ACCESSIBLE FOR AN EVALUATION BY THE HE.41.TIi DEPARTMEAlT
STAFF.
I hereby make application to the Person Caunty Health 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 ifi the site is aitered or the intended use changes, the permii shall
become invalid. „
Cwner or Leg�l Rep�esentative
�-a3- � z
Date
PCHD, rev. 06127/02
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WELL PERMIT
P]LEASE SEE ATTACHED PLAN FQR WELL SITE LAYOUT
Tax Map #: �� 3� Parcel #�.P�_ Township
Appli.can� /� �0 Ic� .5, T'u. ( l c cc rn
Subdivision: � � p
T.nc�atinn� c J 7 � �
Section: Lo�
-Ce F�c� �2d. Q/11c..C�hc c:s /�"l i'11 �d,
� iZc� � ���c� an � � ���
6arn � 3/9 rn�'lc FroM m�Gti«s m%�� ��•
,bc h�nc� k'cd
Ty�e of Water Su�nlv� Individual Communitp Public
�teauire�ents•
Site Approved by �� I�' $� 0 a
Grouting Apptoved bp �µ �o" �3 c�
Well I.og 3 i+ � o- 8- o�
�Vell Tag .
Air Vent
Hose Bb
Concrete Sla.b
Well Driller.
Well Approved By: Date•
� � J �S.�o�K
�Jc�l
'�°5ee Attached Site Sketch'�'*
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be ax least 25 feet from anp bulding foundation.
Other conditions: K C C� (,J ��{ � �0�
! Ue,Stoc..K �ilind �lny Fc�.ci ��'-�i�cs,
crlcc, aS' (ZAd i us around w�( (-�o Prc��nt liU�stoc��
From huv►n� � irtc� C�cc�,�s to wc l I.
PC,��, rev. 09/07/01
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SITE SKETCH
N }ia ra►ci. �c.� I � I�ct r►� Tax Map #�Ef ? Parcel #�3
S di 'si n ►J I H' Section/L t#
� �a �-o�
Authorized State Agent Date
System components represent a�iproximate contours only. The contractor must, flag the system prior to
b '
egznn:ng the snstallat�on to :nsure thatpropergrade �.r mazntazned N-Fo- i7. s�.w
- -- .__ _ 42.89'
Certificai:e of Exce tion. I(we) hereby certify
that I am we are the o�mer(s) of the property
shovn and �escribed hereon, �,mich �*as conveyed
to me(us) bq deed recorded in Book , Page ,
and that said propertq qualifies as an exeept-
ion to the provisions of the Person County
Su�ivision Regulations under Section 16-1.
_ O�mer Date
Owner Date
ir,�.�
Planning � Zoning Adm, Date
Person County, N. C.
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, STATE OF NORTH CAROUNla, CQUi:TY OF ���-�''4•=F-=
, t�.-"1 � :, � . k.�� � ��..�•1' , Rts l � � ( ,
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certi`.y tho! this plat a:as Crprrn unGer my sup�rvis;or from or, eCtuoi
''t, survey mcd_ unde: my ;upc� vision; th�t the rotio of prer.sion cs
�y� �`�-��_ � coltulated by IOtitud:s und deparfures before �Aiuctmon� �c �...� ....
ial _ _ . ..
-- --- --- �
N-57A2-56-W
ti-34-35-02-W N-52-30-�6-W IOEi.24'
99.74' N-35-29-29- W 103.68� �
104.95' �
- -" H-2s-ii-�
-- -- N-45-51-50-W 143.;
S-06-34-2�-W •� �� 103.29�
49.40' s � !_� N_42_o3_IS.W .
Chester W. Holbrook
N-88-30-36-W
129.38'�
N-84-08-33-W ��
59.30'
N-80-30-33-W
69.34' �
N-77-OT- 22 -W
79.T6'
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Driller ID # _ � ,
Com��ny N�me �
:,
Dat�e Drilled . .
Owner: �e� Log
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Locarion. �
Subdivision: Lot #
Tax Map � 33 parcel # ��
Distance From nearest Property Line (Minimum 0� e�onstruction
�
Distance from S e p t i c Sys tem ( Minimum 60 feet) ✓
Tota1 Depth: _ L�,p o f} yield: �� GpM Static Water Level: �p
Water Bearing Zones: De th ft
P o� ft �0 ft_�Q� ft �}
Casing:
Depth: From p to ' a-s� ft. Diameter: G%
Type: Galvanized Steel �_ in
.�
Weight: � '���ess: _/k� Height above Ground: �—
Drive Shoe: Yes No Any problcros encountered while settin� in
If "yes" give reason: � � • ____Y�s �--No
Grout:
Neat: Sand/Cement �/ Concrete Gravel/Cement
Annular Space Width �_ inches Water in Annular Space Yes J'� No
Method of Grout: Pumped Pressu.re �ured De th
Materials Used: P to Ft.
No. Bags portland cement __ weight of 1 Bag Pounds
If mixture (sand, gravcl, cuttings) — Ratio to
ID plates: Yes _ No 4 x 4 slab _ Yes No
Drilli,n� Lo� t .. _
1 hereby certify that the above information is correct and that ttus well was constructed in accordance with regulations
set forth liy the person County Health Deparhnent.
Signature of Contractor �
. ID # � .� ! ]Date � , � . p �
PCHD rev O1/16/02