A34 13Application Date: 2 ��'� Tax Map: #:
Amou_--. nt: Paid:. . .. .. �
RecEiat#: . ParcEi�#•
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� APPLlCAT10N FOR SERVICES
tF THE INFORMATION IN THE APP�ICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED,
CHANGED OR THE.SITE IS ALTERED THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT
SHALL BECOME INVALID. � e 1�
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1) Permit requested by: (Owner/agent/prospective owner): �� a G'¢ .
Home Phone: Address: - -� � � ; � � �,
Business Phone: -�- ' �� � `� �`J
.
2� Name and address of current owner: � Q�. �-�
�� � ��G��,�,� �aX
s�„�v v-a�,v. �.
3) Property Description: Lot size: I,ON.o. Township: I YA Subdivision: Lot#: ��
Directions to the property (Including road names and numbers): ��G�%� vy,ii� •� l�linT�- v��
�'�j�?-d��r Tti E
� i'
4) Proposed Use and Structure Description: answer each of the following questions: � Y�, �`t �
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) Garbage Disposal: Yes � No _
5) Water Supply Type: Private �(new _ or existing �, Public_, Cammunity J Spring _
Are any wells on adjoining property? Yes t/ No _ If yes, please indicate approximate location on the site plan.
6) Does the property contain previously Identified ju�tsdictional wetlands? Yes _ No _
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED.
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR ELAGGED.
➢ THE S1TE 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 o�-site sewage disposal
system for the above-described p�operty. 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
bi� 5 /�`C id0ir/, /n/a / /�-''_�, -r,- . � Z" IJ 1-`'"U !
Owner or Legal Representative
Date
PCND, rev.10117/01
No. of persons to be served Bediooms-1,-2r3,-4.-
Additional appliances to be used: Disposal, dishwasher, washing
machine � r � i 1 � �-
Recommended• Septic t�< <, C' '' (� �-( t( I
` � X; 1, -
Nitrification line:
�"
,
Above recommendation based on information received and observed
soil condition. Sentic tank and nitrification line musi be inspected and
approved by a member of the District Health Departmeat staff before
any portion of the installation is covered.
Date Approved: 1 �-,%) - l� j)
�/��S//Ir�
Countersigned
Signed
Sanitarian
O. David Garvin, M.D., M.P.H.
District Health Officer
(Over)
, 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.
SUG�ESTED INSTALLATION
� (Road
�_
FINAL INSTAI,LATION (Date )
(Road or Street)
�a:. :�,�-:: .. <;;� ;; :,.�; , . -: . : .
VICINITY MAP
LEGEND
NF • NAII FOUNO
NS o NAIL SET
IF • IRON FOU�dD
IS o IRON SET
MP o IAATHEMATICAL
POINT
UNLE55 SIGNED, SEALED AND DATEU. THIS IS A
PRELIMINARY PLAT, NOT FOR RECORDATION, SALES
OR CONVEYANCES.
HAbILEfT—JENNINGS ,�.
dc ASSOCIATES, PA
PROFESSIONAL LAND SURVEYORS
212 S LAMAR STREET - PO 80X 1266
ROXBORO NOR7H CAROLINA 27573
(336) 599-8742
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PLAT OF SURVEY
6ILLY W. WALLACE
WOODSDALE TMIP., PERSON COUNTY. N.C.
JANUARY 2001. HAMLETT—JENNINGS d ASSOCIATES
212 S. LAMAR STREET. ROXBORO. N.C. 27573
NEAL C. HAMLETT L-2465
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oQ;: E�,SS io ;�'y
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' a L-2465 •�
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�Y�:� SUK'll'. �%��
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avt s� t r�n •+o �t.
PLAT CA8 _��_. HANGER 3��
FIL IN PERS COUNtY REGISTER OF OEEDS ON T
.'Z DAY OF �ft____. 20RL •I_IILt 0'CLOCK _M.
�-,.�C.�[�l� �d/__���5lne�'=�--'------------�-
RECISTER OF OEEDS
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NORiH CAROLINA PERSON COUN7Y
NEAI C. HAMLETT ____, CERT[FY THAT 1'HIS
i. - - - -
SURYEY IS Of AN EXISTINC PAR:.EL fOR PARCELS)
NITHIN _ PER��►_'�__ COUNiY AS RECORDED IN DEEO BOOK
Z�_, PAGE ��Se. AW/OR PLA7 _� __�, PAGE _!_
ALl PROViSI0N5 OF NORTH CAROI[NA GENERAL STAiUTE
�7-30 AS ANENDED RECARDINC THIS SI�RVEY HAYE BEEN
NET. IIITNESS YY HAND AND SEAL 7HI5 _,�4_ DAY OF
----�AN�-"-• 20_QS_.
_�J� _c_: ��.�-----------
PROFESSfONAL LAND SIxtVEYOR
t� __ N�AI� F� HAY�ETT__, CERTIFY 7HAT THIS
PLAi NAS DRANN UNDER YY SUPERVISION FR011
AN ACTUAL SURVEY MADE UNDER YY SUPERVISION
(DEED 0�S•CRIPiION RF_CORDED IN BOOK _Z¢_.
PAGE _L4Le. ETC J(OTHER); THAi THE BOUNDARIES
NOi SURVEYED ARE CLEARLY i:�DICA7E0 AS DRAMN
FROM INFORYATION FOUND IN BOOK _�__. PAGE
/• THAT THE RATIO OF PRECISION AS CAL--
CULATED IS 1:_ 10 Q00+ __; THAi TH(S PLAT NAS
PREPARED IN ACCORDANCE MITH C.S. 47-30 AS
AMENDED. 11ITNE55 MY ORIGINAL SICNA7URE,
REGISTRATION NUAIBER AND SEAL THIS _3Q_ DAY
OF ---'�AN�---' A.D.. 20_4_1_.
SURVEYOR �I��. ���'_-_l�+d/ti�_
RECISTRATION NUMBER _______L_2465 ________
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PERSON COUNTY HEAL`TH
DEPARTMENT
q 1955
WELL AND S WAGE SITE, LOCATION INIPRQ3 MENT PERMIT
Tax Map # �3�{ Parcel # � _
Zoning Township��--�c�
Owner/Contractor �__ l��__��A�I�� Date /z. - �'- �o /
Location/Address �'G,Q/ ,/�� .5 ,! —
s.R.#_i��
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
• Lot Ar�
Mobile Home
',SS # Cl�� vull
Size of
Tank
Nitrification Lm'�
Max Depth Trenches.
Perrru ' after 60 months. Permit Void if not in compliance with zoning
Permits may be voi ' ite is altered or intended use changed.
Well and Septic Layout by
Comments: _
Date
by
Approved by
WELL SYSTEM SPECIFICATIONS
vidual Semi-Public IRequired Slab
lic __ Replacement Air Vent
Site Approved
Well Head Approved.
Grouting Approved_
Comments: E��s �
Date Installed by
Required Well La�
Well Tag
Approved by
This report is based in part on infotmation provided the homeowner or his/her representative in the application submitted for this pemut The
environtrtental hea(th 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 misleading
statements provided to him in the application. Neither Person County nor the environmental health specialist warrants that the septic tank system w►11
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�pemutsam Ol/95 rev.1.0
ORIGINAL
���.�� ��I�����T
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���.�����.�. ���.�.�.
WELL PERMIT�
�Pb.EASE SEE ATTACHED PI.AN FOR'WELL SITE LAYOUT
Tax Map #: �J'1 Parcel # � Township
Applican� �; \ �- i i �\ 4 �
Subdivisiori: Sec�ion: I.o�
. LOCdtton: ���4 � M c � �.. V� -�� �
Tv�e of Water Suv�lv: � Individual Community Public
Requirements:
Site App=oved by
Grouting Approved bp C�S � a-�� -��
Well Log ��S �-L-��_��
Well Tag;
Air Vent -
Hose Bib
Concret+e Slab
Well Driller, � ✓an t-�e � � ��; l�� .
Well Approved By: Date•
'�°5ee Attached Site Sketch'�
Wells must be 10 feet from propertp lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other
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PC�ID, zev. 09/07/Ol
PL'RSON COUNTY ENVIRONM�NTAL IILALTFI
�
WI:LL LOC
Date:_ /� /� � �
Owner: � , �
Location/Dixe tion :
s
SR# '
Subdivision Name: ___ . Lot #
Drilling Contractor:��,�_s r„�, �� n _ ,,.
WELL CONSTRUCTIO�V
Distance from Nearest Properry Line�S �/,,�s Distance from Source of
Pollution_ /o d
Total Dep.th:_ �� Ft, Xield:_ S' GPM Static Water L,evel
Water Bearing Zones: De th Ft.
Casin P --��--Ft.�Fc. Ft. Ft. ,
g: Depth: From 0 to��_Ft, D�a�eter:
TYPE: Steel � ' Inches
Galvanized S tecl �-
If S teel, does owner approve: Yes No
Weight: /-3 T}uckness:_ /X � Height Above Ground:T Inches
Drive Shoe: Yes � No
Were Problems Encountered in Setting the Casing? Yes No �—
If "ycs" gi.•c rcason:
Grout: Type: Neat Sand/Ccment -�
Aru�ular Space Wid[h ,3 Concrete
Inchcs
Water in Annular Spacc: Yes No �
.. IV1e.thod: Pumped Pr:ssure Rourt.ci �
Depth: Fr�m-- U :o � � Ft. .
Materials Used: No. Bags Portland Cement Weight of .1 ba � lbs.
If mixtw-e (sand, gravel, cuttinbs) - Ratio:_ �_____ to
ID Plates: Yes � No �
4 x 4 slab Yes -� No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
T�S WELL WAS CONSTRUCTED ZN qCCORDANCE WITI-i REGULATIONS SET
FORTH BY�T�-iE PERSON COuir'TX HEALTH DEPARTMENT.
Signaturc of Contrac��, �_..�.2 � (
Datc