A33 64The District Health Department
Orange, Per�on, C�:atham, Lee Counties
SEPTIC TANK PER1v�,IT
%�o�enL� Rd�el�' �c
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ame of owner ���_ �; .
�Address and Directions '' �•� _ p�
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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
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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.
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.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
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Agplication Date: ��I �O� Tax Maa #: i'�t'3-3
Amount Paid: I�� /
RecQipt #: � Parcei #: C� �'
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�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
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T��,� 33
ZOniOg
APP�
Laa@o
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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
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S!'�
nrior to
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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
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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
. �� ?� � ���� ��
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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 �•
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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
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A thorized State Agent . �_ ` �Date� ` ��� ���
I nstalled By: I/1 ��. Date: �� �� p�
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Applicant: �Io.u-�-� ���.�I ; �c.. � .
Location: T �
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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 .
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PCHD, rev. 07/29/G�
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Tax Map # i�arca! # Sys%m Type (Table Va)
Ovvner/A�piicant Subdivision �
Address/Location Ser.lPhase Lot �
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� 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
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�oliratton Date: � `���'� Tax �la #: 33
.�mount �aid• '1 �
Rec�iat #: l�arc2! �:
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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����
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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 .���.� ��
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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