A34 102�.. - z - ��� •°� . �--- . 3
r�rsniication Date• � 2�,,;"�� � _Q �i" ''�ax �aD � �
���nount Paid: I� •' 0 O �� �'a� 0 Q
R�c2i �: � C� � a �J • � �r�d �: � Q �.
���'e �e �u'��, a� _ -
Person C�urrtv �leaith �e�artmer�t �' � -__ _.�
�vironmer�tai Heaith Section
APQ�ICATION FaR SDiVICPS
IF THE INFaRMATiON IN THE APQ�.lCATtON FOR AN IMPROVE3�fEiUT PERMIT IS FALSIFiE�, C}�lAA1GEi3. OR THE SfTE 1S
ALTER�. THEA1 THE IMPROVENEiJT PE�i11NIT AND AUTHORIZATfON TO CDNSTRUCT SFiALL BE�OME INVALJD .
i) Permit requeabed by: (pwrierlager�prospecSve awnerj: �� i A� rJ�- /� a c� c. �
Home Phone: S� 1- / Ss" y Addr�ess: '', 3 s ti L-� �'u ��hc rf soN Yl� •
Business Phane: ��v - s/�l/-4732 � ,��n . N•G• �.-r S"7 �
� N8t116 8f1d �d�S Of C3JR@� OW11@I: S'f1 M G /� i�'► bs'� �
3� Property D�ptlon: i_at 's�� Tawnshipc �unor�S�rlti-
Directions to the praperty (Induding rvad names and numbers): �=L.Lu.,',✓ /in%�• r i SoN ��
_�J��J iP !� s�{- 3 3� 1 L: o(,w- �'�. /t �� � r k S�> �.. fP,_,;C TvP N
. li�ii YiK f�n ct�u 1.• ., t. 7/f Ul,.-t=t � '
C �
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lt`"Z��� �
4) 1�raPosed tlse and Strudure DescrlQtion: answer eacf� of the follawing questtans:
a) ?roPosed� Existins [1 �
b) Siidc Buiit �, Moduiar Q, Single Wtde j!� Double Wide ❑ '
c) Number of Hedrooms; �, � Number of occupants or peopie to be seived: _�
�� .Base�sses� : Y� Q,. Na�.lf,yes, # af.basemer�t fa�tu.res:. . .� � - ._ �,. ..
__ - _._ _ -_ -.- _
_ _ :.., _.
_ __.. .
fl Garbag� �:�pc��: Yes �, No,� -- . _ -. ;
� Dimensions of Proposed Structure: Width: � Depth: •�1 . H' �j
�/�` i
.
� �2.��
�-es
�.Q �� �'^�''�`�
� Water SupP�Y;YPe: Private� (nevu�ar�exestin9 �� Ptibiic Q Cammunity q Sprmg-�
. Are arry wells on adjoining property? Yes �- No;�lf yes, (oc�tion
6) Please Indicate Desired Sys�em. � ype: (systems can be ranlced in order of yair preferenca)
,�CO11VB�1�OfYd1 _iiAOd�Bd C0�1V8i1t10fl81 _I�l��ila�UB . IMOV�V@
otl�er (speciiyj:
CL�ARLY STAKE ALL CARNEiZS AND LtNES OE THE PROPERTY,
STiaKE THE CORNE3ZS OF Ai1 PftCPOSm STRUCTURE�.
Pl.Ea►SE ATTACH SURVEY P�AT OFi SffE PLAN TO T�IIS APPLCATiON
� hereby make appi'u�ticn to the Person County Health Deparhnerrt for a s�ee evaivatlon for the an-si�e sewage dispasal �system 4or
the abova-desc��bed p�operty. I agree that the corrterrts of this appiiqtion are true and represerrt the ma�dmum fac '�1'ities to be
piaced on the property. I understand if the siie is aitered ar the irttended use changes, the permit shail become irnalid. f understand
that as appiic�rrt, I am respansibie for identiiying and marking proQerty Iines, camess and maldrtg the siie a�ssibie for the
personne! af the Persan Coturiy Healtfi Departmerrt t� candud their evaluatians. I understand that I am responsible for nofiiying the
Heatthh Departmesrt ii mY P�P�Y ���s �Y wetlands as designafed by the Army Ccrps of Enginee�s. �
� 3--0 1
owne`r or Legal Re{�resantatn+e - � r pate
. PCHD. reu 10112f99
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. . . � Applicatian �: ' . .
� . . . Tax M�p �: ;,,� • .
Parael �: i D,_,_.? .._
� �� Penson County Hsalth Dapartment . � . . . ,
Environmental Health Sea�lon
� � �17E SK�TCH.. . � �
.d �a �v�.S - .
'—'" � 8ubdivision/8eotiQnlLat#
.Applloant' Name • � '
��-3--0� � .
►uthorl�ed 8t e Apent Data . � . � . ,
mponsn�e �+sp�ent apprnurtrnalR cnntorrra on�. Ths cantrncfor ntr�l flay� tbe �Yatsm �
rAtnnln� Nia lnatal/Mlon to ln�are lha�pro ep r�d�it malntar�ned . •
, • � . ' �Prox?�e iiawse � cA�'o,� _ �.-�' � �u wse t s ,���- Q}- -�- • .
p•�, - f � �w ��.
Iii � � Qsn L,1�V�I�oh, Q pl�rw�` �•� � YL W1'�C!
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Tax Map �
_ . . . }►pP1[canC
.. .. . . . . LCCBUOIL' �.
P��2SON C�31lNTY E�IVIR�NME�ITP�L HEALT�
�.�1��JE� PLAiV ��R SOIL ARE.4 �►(VD SYST�� �Y�DUT
Pareel# � Z Townshtp 00 s��+ C° P1N
/Joh!'PS Subdivlston Phasdsactlort. _ t�ts
rn
- .�..�;�
. Im�rovement Permit
New �Addition Type of Structure 3�� �s; c�e�Ge
# of occupantsE� �n�C.
Projected Daily Flow: _
Proposed Wastewater
Proposed R�pair.
# of Bedrooms 3 Othet
( 0 g.p.d. � .,1r � Pertnit,�lali
Water SuPPh► rrva� ( �
System Type�
No Expiration
Permit Conditions: �'P� S� �° S� �i` �`' - I
Owner or Legal Represerrtative
Authorized S#ate Agent
Date:
Date: �' 3 `- � �
The issuanca of this permit by the Health DepartmeM in no way guarantees the issuance of other permits. The permit holder is
responsible for chedcing with appropriste goveKning bodies in meeting their requir+ements. This site •is subjact to revocation if
the sifie plan� plat, or the lntended use cl�anges. The Imqrovemeqt Permit shall not be affiected by a change in ownership
at the site. This permi# is subject to compliance wiih the provisions of the Laws: and Rules for Sewage �nea#merrt and
Disposal Systems of the North Carotina Administ�ative Code. -
• Authorization To Coastruct Wastewater System IReauired for Buildins� Penriitk
,i � �� - �p ��� /�
WastewaterSystemDescription:�a �r t' .��sr�e� �� WastewaterFlow: a.p.d. Type:J�+f-.-¢r-.
3 �� .S��en �
Facility Description: ►'oo^� New �9� Repair � Expansion 4
Basement? O Yes No Basement Fixtures? ❑ Yes o --
Wastewater Svstem Reauirements
Tanfcage: Septic Tank sae ��� gal. Pump Tank size � gal. Grease Trap size N� gal.
Trenches: �Total length �� ft. Trench Width �'� ft. Total Area � 1��q, ft ���ct�
Max. Trench Depth: _� ln. A99regate Depth: �'� in. Soil Cover. �� in. Trench Separation �ft. on center
Permit Expiration Date: �3 ` d �
Authorized State Agent Date: U��� .
'See attached site pian and addendum pages for additional permit conditioris.
The type of system permitted ❑ does a'
specfications of tttis.permit •
OwneNLegal Repr�errtative Signature:
not differ from ffie typs specified on �e applicatlon. t accept the
P 4
(�aeration Penriit
Date: S � D�
System Type (in axor�dance with Table Va) \1_ �
This system has been instailed in compliance wittt appUcabie Morth Carolina Generai Statu6es, laws and Ruies for Sawage Treatrnent
and Disposal, and all conditions ofi ifie Improvement Permit and Co�truction Autfiorization. Issuance of this permit implies no
guara�ee fhatthe sysbem installed wiq iundian properlyfor any given period of time.
Authorized State Agerrt Date
PCHD, rev. 03/071Q1
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]�aavaa-o��maa�a.]t � IE�o.m..b�lla.
Name �� �'� ? S • P Tas Map �"" �Parcei # `�
. Sub ' ' � Secrion/Lot#
Authorized State Ageut Date T '
Systrm compoaeats irp�eseat appm�rr conmurs aaly. The caanacmrmuat&rg the srysum pdor w begmaiag� the iastsllndoa m�
;..e,,,,r thrrPiraPa'grsde ia ma�ttiaed �
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IF :��n.s�aca.��n,-n.a�airn��.71 I�-'a��.71�1�m; .
WELL PERMIT -
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map � Parcel � Township:
Applicant• � � S
5ubdivision: _ Lot #
Type of Water Supply: �,,, Individual _ Community Public
��' Requirements:
��
����� J� Site Approved By:
Grouting Approved By: _
p�� � Well Log:
Pump Tag: t�S
Well Tag: � Z `7
Air Vent:
Hose Bib•
Casing Height:
Concrete Slab: ot l s�
Well Driller:
�
- � .. � - � . �! JL '� � \ E? .�l �-
****See Attached Site Sketch****
Liner:
Installed by: ,
Depth set: _
Grouted:
Date:
Water Sample:
Wells must be 10 feet �rom property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
Date: �
PCHD rev O1/27/04
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pf�o1�6 a o � .�
I��.��-�� � ���.I1 I�3L��.11.�1�. � o� � - ° ° °
Applicant: �( il�� s . . - ,
Locaiion: __.,_ . � I ,. ,_ n
e
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System Type (in Accordance Wifih Table Va): -� �
THIS SYSTE�l1 H.�S �EEN IiVSTALLLD 1fV COMPLI�►NCE Wli'H APPLlCABLE . NORTH
��ROLINA GEIVE€iAL STATUTES, RU�ES FOR SEWAGE TREATIVtEAIT AND DISPOSAL,
AND • ALL CONDITiONS OF � TI-!E lMPROV�MENT PERMIT AND CO�ISTRUCTION
AllTHOR ION. �
. '�, R��-�S . .
� uthorized State Agent Date
installed By: �,l . 1�I{_'S Date: ( ��d � �
` � ���i°t�
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PCHD, rev. 07/2Q/04
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'/� ��� B 7i.r ������70 �l'����3r i ��YB 'i���Y.v�9�7 B Z " 9 �� Y� � �
► ax Map # t�J �� Parce! # 1�/ oC _ System Type (Tabie Va)
Ov�mer/Applicant -* � Subdivision
Address/Locafion SeclPhase Lafi # �
Se��c.'�'anE� lnetaa Da� N6tra oca#aora an� In�#aa a� �
State �ID/date ��
Capacity ( Q�
Tee and Fi)ier -
Bafffe
Sea{ant
Riser (ifi applicabie)
�'ank Outlet Seal
Permanent Marker
PurnD T�n{t
- �a ac�t
Water roof 1Sealant
Riser
Water Ti ht
Purr��
Check Va1velGate Valve
� Ant�-sip on o e
P,�e1^ �/ Trencf� Width $��' ft.
� Trench De th 2 in.
• T,rench Len OU ft.
Trencf� Gtade -
Trench S acin
� Rocic De th and Qual'
Dams/Ste downs etc.
. . Pressure Laierals �
�41arm visa�le and audible
Electricai Com onents
� Rate m ..
A roved Pum iVlodel
B(ocic Under Pum �
Pum Removai Ro e/Chain
. �Dis�a�ibu�ion:Systern
� Seriat Distribution
Pressure an oi
Low Pressure Pi e
A r. Pi e i�iateriai and Gra�
Valves �
�
�
�
I�
Pipe. Sleeve
Tum-upslProte�tors
Ftequireci� Se�ac9�
From� Welis
From Property lines
Surface Waters
Public 1lVater Suppiies
Vertical Cuts (>2 ft.)
Water Lines
Ve�iicle �Traffic �
• . �Easements/Ri ht of W�
�er
;o . Easements Recorcied
e e erator oni
Tri-Partate A re�ement
Cc�ramen� . .
5.✓
��
pcf�d rev. 3113/01
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�1CL'WA]�a�717L]L33�C]Ca��.�l.�.. 3� 11�4-"'1CI:1L1�� LJ(�11K7 VUlwu�u � � � � _ ,
Owner: ,�
Location:
Subdivision:
Jrout Log
Tax Map�3� Parcel # 1 D-�--
Lot #�
Well C�ruction
Distance From nearest Property Line (Minimum' 1� feet)
Distance from Septic System (Minimu 60 fq et) ��
Total Depth: � ft Yield: � GPM Staric Water Level: �_ ft
Water Beanng Zones: Depth _�-� ft ft ft
CAsing: '
Depth: From _ J.�� to ���� ft• Diameter: 6,�_, in
Type: Galvanized Steol _ -- �
Weight: �,�. Thickness: I�� Height above Ground: in
Drive Shae: ��Yes No Any problems encountered while setting casing7 _Yes _ No
If "yes" give reasan:
Grout:
Neat: SanrUCement t� Concrete GraveUCement �
Annuiaz Space Width �� ,,� inches Water in Annular Space Yes ti1Qo
Method of Grout: Pumped Pressure ✓Poured Depth �_ to ci �t.
Materials Used:
No. Bags P�riland cement Weight of 1 Bag �� Pounds
If mixturc (sand, gravel, cuttings) — Ratio � to �_
ID plates: `!Yes _ No 4 x 4 siab !-�es � No
Liner:
D�pth: Date Installed:
Drlll[ng Log
From To Formsttion
0 < <--
Grout: . Installed by:
Location Drawing
I hereby certify that ihe above information is correet and th this well was construeted in accordance with regulations set forth
by the Person County Health Depa j
� ID # O 3 I Date �- � 7i� f'
Si��ature sf C�ntruct�r �-
Pump Installation Contractor:
Pump Depth:
Pump Make & Modei:
Pump InstAllment
ft Static Water Level:
State Registration Nuniher:
ft
Pump Size and Rating: �
hp bm�
I horeby certify that this pump was installed and the well head completed according to ihe Person County Well Rules in effect
on this date and that a copy of this record has becn provided to the we}1 owner.
Puma Installer Sisnature _ Date: PC'HD rev Ol/2']/04
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