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A33 64The District Health Department Orange, Per�on, C�:atham, Lee Counties SEPTIC TANK PER1v�,IT %�o�enL� Rd�el�' �c ,"", - "`� Dat _r . , ' ~ � � .�) ame of owner ���_ �; . �Address and Directions '' �•� _ p� ��_.. + wif ;5j� ��ej�� f -.�+ l f �/ t !: r\ , : '� ' ��� �fC..,i /`'1.�. � ; `d a.- � � . Person or firm doing installation: .��-.c<s Address u .�r��: No. of persons to be served bedrooms 1, 2, 3, 4. �� Additional appliances to be used: Disposal, dishwasher, washing machine Minimum Requirements: Septic tank /-� '' 1'. �{ � � ,J � . I'.;f. Il.'.a � t Nitrification line: M� ' ' � � , :�: _. _ � � t.. � .- , Septic tank and nitrification line must be inspecfed and approv�d by a member of the Heallh Department sfaff before any portion of the installation is covered. Date Approved: ��„ , "�i:�����`, .-rP _ ` p %`Ff � � By. ' . • `. S`�nitarian `� ` ,�''` �,i� _ � i` � �' , O. David Garvin, M.D., M.P.H. District Health Officer Countersigned � (Over) E: � � . ..:, NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on adjacent property, etc. Write in measurements in order that installations may be located at later date. a �� O � . .. � '�� ��. �� ..._, � e!' , � a� f�^ /�%'' / � v'/. a,�S� T � . � � ��" .."•w • . ,1 ;.q,, '� 'n ; - � i .qpplication Date: i�l �'� l �� ` ,�mount Paid: DD. va ' Receipt�e � a� 5� Person Countv Health Department Environmental Health Section APPLICATION FOR SERVICES Tax Map #: �33 Parcel #: � IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED. CHANGED, OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID 1 j Permit requested b:(Owner/agent/prospective owner): �o.B�E.�I'�f�L st�KL/L.� Home Phone: o Address: //3� .EAtJ�sr�S Ci/• Business Phone�� 99'Z • fIU�l6 SF�No,eA .L1C. .Z �3 S/3 2) Name and address of current owner: o f� / L � L. 3) Property Description: Lot size: r� �ownship: v�0 .c�,yl.0,/dl Directions :o the properry (Including rQad names and numbers): C 4) Proposed Use and Structure Description: answer each of the following questions: a) Proposed � Existing ❑ b) Stick Built C�, Modular �, Single Wide 0, Double Wide 0 c) Number of Bedrooms: o d) Number of occupants or people to be seNed: e) Basement: Yes 0, No �If yes, # of basement fixtures: � Garbage Disposal: Yes 0, No e' � � g) Dimensions of Proposed Structure: Width: � Depth: �J 5) Water Supply 7ype: Private �new ❑ or existing e!� Public ❑, Community ❑, Spring ❑ Are any welis on adjoining property? Yes [�No ❑ If yes, location WEST � 6) Please Indicate Desired System Type: (systems can be ranked in order of your preference) _Conventional _Modifled Conventional _, Alternative _Innovative Other (specify): CLEARLY STAKE ALL CORIdERS AND LINES OF THE PROPERTY. STAKE THE CORNERS OF ALL PROPOSED STRUCTURES. PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION I hereby make application to the Person County 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 if the site is altered or the intended use changes, the permit shall become invalid. I understand that as applicant, I am responsible for identifying and marking property lines, corners and making the site accessible for the personnel of the Person County Health Department to conduct their e�aluations. I understand that 1 am responsible for notifying the Health Depa ent if my propert c tains any wetlands as designated by the Army Corps of Engineers. /.?-,�/-v v • Owner o al Representative Date PCHD, rev. 10l12/99 _ .��.,�._ _ _: _... r.__._ .__ �,_ .._._. R_ _ -- , ._. f R� , _ + r, � . _ _. J � � - ; � .. '� $ � � ' , ' � . 'r c . -m ' ' I t �` s' " �-�`--^ .r ��N ���-35 - DO. g '.E � ' + � rc36. Z3' . M_14 _���. � s ,', ►+. �, � �"� w � m _ � \ � ' � 61. T T � µ�,� '� � �°p �, ��� � �r�7� � •°� � � ` � � � F _v::. ^�,, �� r• '' �i'� " •�i �► '� � �` `•• �` • _ .. • L. � "` f { �, �: � �' r � �i � �b . � .. � . � i '�� �� y q ^ p,tOp R � � �,� 6po4� ! � � '.} - _ - . i 1 � � '�.� �+ /+ tia' C � � 1 - �<' . -�I \ P ' � � O � � R{� "- � � � � _ i..�- .. �� `Q 1 -• a� �K�14 � A _:. ; 'i h „r A ...... O r t � '.�j NM� � 1�'"�j � �'� ��. • Y „ . - ._�.. '"' �� " �Z ' 1ly ` 'b ` ' � '. � � M � � A � `s 7�',•.-�'' —'""-� � � b � �"i ,•Q + � � � . ' . "� � ��.� +r0' ` ut ' � � w r '� :' r�' r � � N ' ' � ^' • � `. 3 . _ _ � � � A � � � 4 i, : v R 1 � C ",ti: � � `s �,: � �� '' � � � � ~ f r � '.; ' _; H w„ N, � � � � ` �ti� � � � ,r � � = f .I � �q �� � Irr + o � ; � � � ,� � ` � 1 1I, q � / ` _ 4 i� • � � y, � � �r � +� � � 4i � r, � ` � � ��� ��'� � QI K /� � n 4 r , '' � � i p � �� � � � � ' . � i+ � ,� � Y{ � � / � O � N � � u� � ��" �` � � '� � �� �J � n ' }��A� . +� � �" � � � � ' � - � ,,x 4� �, � �� �-- _ _ _ " — ' _ � � � � �+� ; � 1�" � � ' _ _ — r ' ' ,�� � N � � �, �i, � t' � - � !' � p, , f ' �'� �� . � o , �� ,� � �� ' `� � � �'�" . � �' �� o "' , � ; ', . �,+(� ".� _ � �� � " { � � # . . . � . •'� � � a � _ � . , } , . { , � � k .. - � � � S � ' � � ' * � f ' �� � , . � � r ' t � � ., • „ . 1 , ' � � � � p� ��.� � � ., . , �• . '� � � `' _ � � � _,�: '� �.��.�'� �. , s -or - s9 -oo-w � , i'a Vi :� '� `i � , � "y cr� ° � ' � � � � , � ' , � ��� .. . E. ` � ` Q� � M � � �,.z.�.:'� ,.. � b p ,,F;� fd . ` � E , r-- - � � , £ ,� � _. � � ' _ Agplication Date: ��I �O� Tax Maa #: i'�t'3-3 Amount Paid: I�� / RecQipt #: � Parcei #: C� �' �-� 7 ����5� I�'I�I� ���T � - - --- � � �1�T'IL" � �aawa.a-oaa---�-„ �o��mll. ��o�.���a APPLICATION FOR SEi2VIC�S CONSTRUCT SHALL BECOME INVALID. - 1) Permit requested by: (Owner/agent/prospective owner):��•C L� Home Phone: � b� �7 Address: �i° • Business Phone: � _'��v.ei�l- �G ��34/3 2) Name and address of current owner. ,� T �.¢oc�i�f'� �ir,/ uS . �, ,v�o.2A �'�Z' .c"734/3 3) Property Description: Lot size: ,� . Township: L�,��- Subdivision: Directions to the pro Lot # 4) P'roposed Use a� d Structure Description: answer each of the following qu stions: i � a) Proposed r/, Existing Type of 5tructure:/��o�_/< /��vs ao� Width:_��, Depth:�_ b) Number of Bedrooms: _�� Number of occupants or peopie to be served: �_ c) Basement: Yes , No _ Will there be plumbing in the basement?�/� d) 6arbage Disposal: Yes , No �/ � 5) Water Supply Type: Private ✓(new _ or existing�✓ , PublicJ Community_, Spring _ Are any wells on adjoining property? Yes� No _ If yes, please indicate approximate location on the �site plan. �'Jd,eT,� ��i �.e•rv � 6) Does your property contain previously identified jurisdictional wetlands? Yes_ Wo_� PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SITE PLAN iV1UST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY LINES AiVD CORNERS MUST BE CLEARLY MARKED. , ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST 8E STAFCED OR FLAGGED. ➢ TD-IE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE tiEALTH DEPARTMEAIT STAFF. I hereby make application to the Person County Health Department for a site evaluation fo� the on-siie sewage disposal system for the above-described property. I agree that the contents of this application are true and represent the maKimum facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid . / / Owner or � 4.5� Date PCND, rev. 06/27102 � � ���sao� ca��rrr ��tRONtwe�-r�� ���� T��,� 33 ZOniOg APP� Laa@o �� � TcrmsMe l.(A Yl Y 1 t Subdtvl�lo� 3�dloa I.oC � Improvement Permit � A buildin rtnit cannot be issued with anl an im rovemer�t ! New ' Repaic Add�ton � Type ot � S_ �� � Water Supply W2� # cf oax,pa�s N� �•of 8edrooms �� Other � Q�Th rnan. saseYneat? _Q�, ease�ent Facaues? n/'n Projeded Da�lY Row:141�.' . 9-p.d. Penn� ValtdFo� P�Po� � SY� �'YP� GOn �iG�v�.� Pump Required?" Yes a` � No Propased Repair: hVP o-�� Perm'tt CondBions: loo'' ti. we �I / vs � � a,f e,- � s-z�e Owner ar L.egal Rep�ese�re S�: Autttorized S'tafe Agert� Y�rs 0 No EYp� �.�o�, �,�r�r,h� �� h�.�--�.-�., �( o w i.z r _ .�n ..`fe _�c.r � . - oac�:�—G -- ol nat�: 1� 3 �-o i The issuance ef this perrnit by the HeaRh Departme� In no way guatarnees the issuance oi other p�mv'ts. The peirnit hotder is res�ar�le for ct�eGdng with appropriate goverrdng bodies Irt m�g their reqtrirerner►b. This siba is subject to revoc�tiea if the siba plan, plat� or the itrteaded t�e cl�angea. The ImQrnveme� Permit shaU not be affecLed hy a change in ovmeiship of the aite. This permit is subjec! bo camplianc$ with tha provisioas of the Laws and Rules fo� Sewage Treatrnerrt and Otsposal Systems of the Nerth Camiina Adml�istrative Code. Authorization To Construct Wastewater Svstem fRevuired for Buiidinct Permit) Type of Wastewateir System _ I.AiZ ✓8��t7Y�/ WasteYvaier FiaW: 0 D ,�.d. Fac�y Type: Q�" e S� o , New 9�air OE��ansioa Q Sasement? 0 Yes o 8asetner►t f ac6ues? t� Yas � Wastewater SYsbem Reouiraments ' ' - -.Sept� Ta�c Size: �Oo� ga�oc�s Pwnp T�Ic Size: gaRons Total T� Length: / 1D fie� Ma�dmum Trend� Deptlr �� iru��es Aggtegabe DeptkL in. Ma�amum Soil Cover: 6 ind�es Tr� Sepera�On: � Feet an C� Ottter: ' . Perrnii Ex�ration Date: l r 3� — 8� Authorized State Age� Clabe: ��`—�—o/ • The type af sys�em permitted 0 doe9 Cl doe9 not. differ fcom th ty specified on the appiication. I acaspt the specificattons af this psrmit OvmerlL,egat Regreser�tative Signatitce: Dafia: s2 G- � . • PC7-iD, t�v.11/18199 m .4 � S!'� nrior to � sc�1e: r'� = 3af . . __�_.. _.. .. ._....__..._._...___..._ ... _._ . ��r��n Caunty �lealth. �Department � Es�dironmeniai Hesith Seciion . T�� AAap $: � 3� _ . . � � Paresi �: � � Si'i�E Sl4ETC� _ . _. __ �� �;eL� . lcarrt's Nam � Subdi�ision/Sed(anlLot# ��3o-D� . � Dete . . � rapr.esent appra�r�e ca�tnra� only. The condactor m�t flag the sys�eae - r8 /hs �ion io i�ure that pmPQRTade ir ma�iitained � ��is�l,� se �fcic� �-� '�;,.c t�se ' Dr�ueway �1 1 � �$�Yq`n.MUM _ ' � �O � � � -�,�k a.,.o� ' r `���'n� �VtL�n���. � Q o K 3�'�� � c�� �ti�`v� c,� � � Z��,,��.,� , 9�����st,{,�. 8A ���' )��� ���� �� � "-� � � ��� 1L I���-a.a-��.�.-� ����.IL IFII��.11�1� Applicant: Location: Permit ' for Type of Facility: # of Occupants Proposed Wastewater Proposed Repair: Permit Conditions: Owner or Legal � Authorized State �� T�x M��� ' P�.rcel # S�u�hcilivi�s�ion Ph�as�e'Section Lot # Improvement Permit Five Years No �zpiration of Bedrooms Signature: �, � New Addition Projected Daily Flow � g•p•d. Supply _ Type: Type: Date: Date: The issuance of ' pernut by the Health Department in does not guarantee the issuance other permits. It is the responsibility of the applicant/prope owner to in sure that all Person County Planning and Zoning and Building _ pections requirements aze met This Improveme Permit is subject to revocation if the site plan, plat or the intended use changes. Th provement Permit is not affected by a cha e in ownership of the property. Tlus permit was issued in compliance with the provisions the North Carolina Zaws and Rules r Sewa e Treatment and Dis osa! S stems' (15A NCAC 18A .1900). Neither Person County n the Environmental Health Spe ' t warrants that the septic tank system will continue to function satisfactorily in the future or that th ater supply will remain Authorization to Construct Wastewater System �Required for Building Permit) * See site plan and additional attachments (_). Proposed Wastewater System: l�� ��� � Type� Wastewater Flow ��o g.p.d. New Repair� Ex ansio Soil LTAR: .'j c'� g.p.d./ ft 2 Type of Facility: ����]�S . Basement Yes �.No Wastewater System Requirements Tank Size: Septic Tank: ��` S�gaN Pump Tank: ' gal Grease Trap: ' gal Drainfield: Total Area: �7� d sq ft Total Length 1C�� ft Maximum Trench Depth � in Trench Width � ft Minimum Soil Cover: � in Minimum Trench Separation: �_ f�. �. Distribution: Specifications: Box � Serial Distribution Authorized State Agent: �( Permit Exniration Date: . The type of system permitted is X Conventional the permit: Owner/Legal ltepresentative: Pressure Manifold c- � �'�'�— �' � D Innovative Date: �j — �(— p5 Alternative. I accept the specifications of Date: PCHD7/30/2002 . �� ?� � ���� �� . - � � " ������ 7Eaa�aa-om����.Il � IE�Tm�.Il�]{s. STTE PLAN Name �� 5�� C'�� �� Taz Map #� 3� Parcel #�� Subdivi o Section/Lot# 7J' � Authosized State Ageat Date � S,ystem compoaeats rrpieamr ap�rr coamrus m!}: The canuacm�rmust9ag t6e sysaem pdor m beglaamg �e insr�ll�tioa m inci.re �at pmpetgt-Jde is �mtatned �ir ✓�l,u >� 1 lA Y f%U`t l/ 1'L+e S OrYI �J vt, �7�L/" l.f '�'j l�Z C� �c 1� �fN �"t'i�l �• � (b�`� � �,.� Z� �� C�a � l�� ��-r� ; s � �. ��p ��~ �<<�� vu�� J� �1 . � . � �� . �� �� ��� . . � p�'� .� - . - s�� �c� ��G SQ 1on - - . _ ,� �`'`'S�' . ��� . l l l � l �-' '�u� �� +�o�o�ro s�C IVOv�-2. � l�r� s Cl., flo(. t:�r �` �,�1 �`_'�s ���r �t'a�,,l ,f rcK /�Ck r.1 � � �� 0 unG 3 �� � G� � p� u.� ��' sec�; ��., a-� v �� ��� + rocK. a�ol bac,��'� l I� w►+� Cl-��, So � � j. �. �''�� �' rcxn, �. os1�z/oi ���' ; , ) f ���� �� ` �^ � � ���� ��av�n�-��a�rnn.��rn��.IL IC���.Il.�l1a Applicant: �)�� il--� Location: � �— f`S'� � _ C�,�',,. ��► T��x Map / F��rcei # � S�ubci,ivision Pha�s�e Sect�ion Lot # # of Bed�rooms Operation Perr� it System Type (In Accordance With Table 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 CONSTRUCTION AUTHORI 1 N. ^� %�• � �r'v'� l� �(�" ( �•fn ��1%� A thorized State Agent . �_ ` �Date� ` ��� ��� I nstalled By: I/1 ��. Date: �� �� p� 1`�.0 � yr3 r� � �� _� � ���� � s��z � y,����� 3 �S12 r< < « , ��`� s�n �z �� s� , �Ll� i�- ; =J �� u s : ri . ` t� u _ � _ � n� � �� ^ w �i • 1 • n u � ��{ �� � ;i �il 1 ( � r • � � � - ' '� • 1 l _ i 1 1 � '1 ` '� � r � i� 1 � � i� �i i �i � �+ _ `` i � r . a ,; 'r - �i � . L — , � a a � ' � �{ r r� r- ' ' � ;( i Y ;; � " �'` , - _ _ � ' • _ - -? :: _ �,! - ', � �.i � - � � � �� �i �i 1 � _ 1' ii ii �i il �i � �� " � �e � - • • �, �t. � ii ' �i '• � i �� 1 — — _ I ■ 1 � 1 ■ 1 � � r _ � � _.___ ..r ._._. �� i' L' i M \ ' lyl � I I � � 1. 1� � . i i � • �i � • y �! � � 1� I , `. I � � i 1 � ', ,, y i � � � i � � + - - s • - u � � �i 1i _ �1 ' - � , �� • : �� �� ` � 1� u i� � `� � r - - � � j i� j : 1 �� ;, �I 1 - r � - � - I u � - u 1' �! i II �� � �1 iV j i • � � • 1' - - � � �' ii F Fn - �` _ , 1 �i � _ � � I e � � j �i � � , i + ^ }I s � i1 r� �� i � � � r • V r`0 � ` f 1' �1 !I �` r •_ � � � '` • �� '..' 1! i� S 1' 1„ !, i� i� '{ 1� 1 ; �� � 1 _ t� r � , i� I u -.■ _ �� 1 �lG���\ � / � l7 l L.+� �(��. ��� �1.� t�" /�j �\ 11Z�JLS � -���i— it'�sllfl�U L;l ��j� �.�� �� �l'ti.11 �� � .t1. V �Z JL°WI:JlYJl11/U�tIO° � �, s � � �._ � C� � �.T�T�� ��a o�� I��.�a-�,.-„ ,.-,,.,, ��.�.�1 1�L��.11�. � oii �- o 0 0 Applicant: �Io.u-�-� ���.�I ; �c.. � . Location: T � � 11 �� ��;..�s� � s G� Qc �{- P� . � � � : � , �� :if �_ ,� � ;� System Type (in Accnrdance With Table Va): �ci THIS SYST�M HAS �EE�1 1NSTALLED iN CONIPLIANCE 111ftTH APPLICABLE NORTH C'AROLlNA GEi�ERAL STATUTES, �tULES FOR SEINAGE TREATflItEi�ITT AND DISPOSAL, AIVD AL-.L CONDIT1oNS �F � THE lillIPROVE�VIEiVT PERIVIIT AND CONSTRUGTI�N �1UTHOR(�4T101V. � � �/3i /bs � Au horize ta e A rrt . Dafe Instalied By: �—.�.�C-l� t-te� Date: �/ 3�/D Sr . � � � �''�j> �o w �1 La�.aE� ..- Z �. ��� � � G.,.--= �',�'`4-��S ���r Cv ��.�� w�.C�' 6� .�f���-�' �.,.,� se� �'e � �iSC.OfJNfL'�"-'�� .�N� �,� -�', t 1��. PCHD, rev. 07/29/G� � �����G �'��� �RlS���`���� ��E��9S? ��'��e �➢ � �� Tax Map # i�arca! # Sys%m Type (Table Va) Ovvner/A�piicant Subdivision � Address/Location Ser.lPhase Lot � ���P$6C ����t �l$8� ��$� 9�'9 1C�$8�i'p B��S 9'!9'�@� 1�� ' � State�ID/date Trencf� �dth ft. � Ca ac' ai. � � Trenct� De th in. Tee and Fiiter T.rencii Lenath �t. � Baffte - Seaiant � Riser ifi a licable � Tank Outlet Sea! Permanent Ytarker . Pump Tank State D ate Ca aci al. Watemroof /Sealant Riser Water Ti ht - � PtcrYap Che�l� ValvelGats Vaive. � Anti-s� on o e Fioats/Switches �11arm visable and audible Electrical Com onents � Rate m A roved Pum Model B(ocic Under Pum Pum Removal Ro elCt�ai . � Distribution. Sysien � Serial Disiribution ressure Man ol Low Pressure Pi e A r. Pi e I�liateriai and G� Valves Trenct� Grade � Trencf� Spac9ng� Rocic Depfih and Qualiiy DamslStepdowns etc. Pressure I_atterats � a Hole Spacing - o e ize Pipe. Sleeve Tum-upslProtectors Fd�cguired� Seibac9� From- Wells From. Property lines StructuresBasements i c es rainage ay: SurFace W�ters Pubiic 11Vater Supplies Vertical Cuts (>2 ft.) Water Lines Ve#�icle�Traffic � Ad�acent S'ystems � �EasementslRight of Wa Other Easements Recorded Comanen�s pc;�d rev. 31131a1 0 -� - - :a� � ���� �� �- .�, ` _ _ �.. �� � . _ � _ �, - � _E; ...,_ �: � �: �: - �: , ��, Taa �g # `� � par�i # • � � ♦. ' s�■ � 'r.::a�� - •- �a � �r 1�.. � r.t �. r� ���� .. .v w:..u.�.-+rr � � _ _ � �. �� 1 1-•� 1,� a .�.,. '�' s / � � � �� / � � � :' _.: .. _. ' • ' V = �, .. ' ,.. �.� � �- . • 1,/ � i i.- . .;., . _ � , �.�/ - � ,. ... .. � � � � • �. � • � P�a'st 3.n� � Wa�ba SapQ�y: l�t�L°�� . Se�ic gpsi�n �� Fo� �sf�al Basi�us� . . # B�tooms �' # R�_� � � ' ' �'l�lC l%L�+-v��IvL� . ( • �32l� �nZC Oc . l�j,#ti$r•,+inr� � C �� l�3 (7�� ( . .Date T„�tt�•. �f `" �1��� � C� O�iersta��q�ic� �� . c�..��a������t����� 4�� r�� ��� ��a� C-���-� ��' w �. _s c�� . r,,�.�., •`�v�-�z �� _ �-�-e.�, ✓�c.�, s •4> � rPA4�'�e.� � " � �SI�e-�-�r� �� � � e �re. ., . . • . r�,� 1 c�t� C�-��-�'�,�, � � � ' � . t , • �Iaer�.1. =.s��% � � iu la:,�r► ...� -r �' /, �• ' i .•�� � '�°- �Cp,N�'•''`e,�yQ �i�tl��� . �� �K' �<-(M� c�c.-�.`�• �oliratton Date: � `���'� Tax �la #: 33 .�mount �aid• '1 � Rec�iat #: l�arc2! �: ��� ' ���,�� � �I�1�..� �� �r�-� a-6 4� - � � ��'�`�' � \ 7�m..�raa-��-�- --�-�- •esm.�� IE-7roa.1l��a �� 1/ �C Y APPLICATION Ft3R SE3ZVIC�S � " �` ��i, � . V`.' . U IF T'H INFaRMAT10N IN THE APP�Cl�1TlOAI F�R AIV IMPRONEAAF.AIT PERMR 15 IIdCORRE�. FALSIFiE�J. CHANGED OR TiiE SITE 15 ALTERED THE�d THE 1MPROVE�IIENT PEi�MIT AND AUTHORIZA'�IOId TO . CONSTRUCT SHALL BECOME IIWALID. - 1) Permit requested b: �wneriagentfprospective cwnerp v��2 .� �Oct�l,•�� Hame Phone: S' -- � o Address: �'.off� S • /J: 6usiness Phone: f if _ S�' =�//�,/� s�sc.2.¢- !V� �73�/3 2) Name and �ddress ofi current ovmer: vR �T L Qoc1,/ .C� � .�. � � 3 3) Property Description: Lat size: Tawnship: Subdivision: Lot# Dire�tions to the property (Induding road names�and numbers): �• 4) Proposed Use and Structure Description: answer eaci�t of the foilowing questians: a) Proposed . Existing , Type of Strucbure: Width: � De#�th: 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 Dispasal: Yes No _ _ 5) Water Supp►y Type: Prnrate _(new or existin4 ), Pu61ic� Camm�snity� , Spiing . Are any welis on adjoining properiy? Yes No _ tf yes, pleasa indicate approximate locatiori an the �site pian. � 6) Daes your property cmntain_previously iderrtified �urisdlotional wetlands? Yes_ (do_ Pl.EASE NO'TE THE FOLLOWING: ➢ A Pl.AT OF THE PROPE�2TY OR SIT� PLd�V �AUST EE SUBMITTED WRN THIS APQl.1CA�tON. ➢ PROPE�TY UNES APID CORNERS MUST BE CLEARLY MAR6aEfl. �, 9 THE PROPOSED LOCATION OF ALL STRUCTURES NIUST 8E STA�� OR FLAGGE�. 9 THE SRE MUST �E READILY ACCESSiBL� F�R AN EVALUATION 8Y THE HEALTH DEPARTME�YT' STAF�. I hereby make applica�on ta the Person County Health Department for a s�te evaluatian for tfie an-siie sewage disposal system for the above-descrihed property. 1 agree that the cantents ef this appi'�cation are true and re�resent the maximum facili�es to be placed on the progerty. I understand ifi the site is aitered or the irrtended use ct�anges, the permii shall became irnaiid„ / � Cwner or l,.�ai Representative _�O.o �. Date PCiiD. �ev. U6J27/U2 �1�y )��� �� �r���� `�^ `L � ���� ���.���*'i+-n'�T'n ��3"��.� 1L 1L�B�.�¢� WELL PERMIT PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Map #: R?J3 pazcel #� 9' Township A,pplican� �,Obe rk L� 2 ad C i.i FF Subdivision: � � � Section: Lot Location: S I I�i � C�n cor� - Ct FF c� (�d � lJ (►1 ��h� r�tS iYl � l l� � �pti�s�.� �� u��� �� �� F�� a-� a�� � I J3 7 .� � - � ;� . � � � • � • � R�uirements: Site Approved bp ✓3� �`�"�'"�a-' GroutYng Appzoved by c��" � n' $'�a Well Log �Xlell T$ Air Vent Hose Bb Concrete Sla.b Well I)riller. Conzmunitp Public L� �� 107 �i�y � ►� x ��� - D � �z� Well Approved Bp: Date• '�°5ee Attached Site Sketch'k* 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 biulding foundation. Other conditions• S�� C�-S � n� i1 �� n r� rn u,r, , rc�, _�. 09/07/0� 10/09/2002 10:59 336-388-5940 .. �� ._ ____. .. - -- �-�,��. Ss .���.� �� � ������ IL.��-a, a- � zra�. a� x� tE.ca.1l I�'3� �c e..�,t.1kn. EVANS WELL DRILLING PAGE 01 Dri�l,ler ID » . Com:Er���ny N���me � D��,te Dri('led , Ou�uer: ... f-- We� LOg Location: Tax l�ap �g� Parce� #� _� Subdivision: Lot # -.�..�. WeU Const�ructiou Distance Fro�n nearest �roperty �ine (Minimw�r� 10 feet) �'' Distance from Segtic Systeza (M.znimum 60 feet) � Total De�tkt: _ d� g Xield: � GPM Static Water Level: ft Water Bearimg 2ones: AePth - fa � ft__��a � R ft Casing; Depth: From /� t (, �� R. Diameter: t%� � T�rpe: Galvaaized Steel z.%�_� Weight:1,�� ���a5; ���r �eight above G�o�tnd: _ 1�- in Drive Shoe: _,� y�S �o �y p�ob�ems et�countezed while settix� casin � If`�es" give,�easo�n: � �• —,.�'eS `'�"�o Gxout: Ne,at: - San.d/Cemezzt --�'� Concrete � Gravel/Cemen�t �� Annular Space Widtb. y 7 ^ inches 1X�ater in Aqnular Space Yes �--No Method of Grout: Pumped �resswe _�-�aured De � t�y Materials Used: p _., F� No. Ba�s portland cexnerit �� yy���ht of 1 8ag �� Pounds �tf mzxcure (sand, �ravel, cutxings) - Ratio ____,� to l YD ptates: �'Yes y No 4 x 4 slab �'Yes � Nu Dril�ing �.og Location Drawing ,�'rom To k'o�rmation I hereby certify that the above inforination is correci and that tk�is wcll was co,ns�uct d in ardar:, set forth by the person County H th p��em�. 5ignatnre of Contr�ctor . TD # � �, I ate / o with regulaaons a rev o1�16/02