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A35 41B�. . . • �,pplication Date: ��' J �', �" -' Amount Paid: � 06 . U O Receipt #• 3 a v� P 3�� �o � 3 l� � � � ���`?_.�� ���� �� '_'— � � �.� � � � ��.�aa-��.�-�--�- .a��.m.Il �%��.�.IL�1� APPLICATION FOR SERVICES Tax Map #: Parcei #: IF TEiE INFORM�►TION IM THE APPLICATION FOR AN IMPROVEMENT PERMtT IS INCORRECT, FALSIFIED, CHANGED OR THE SITE IS ALTERED THEM THE IMP�tOVEMENT PERMIT AND AUTHORIZ�►TION TO CONSTF�UCT SHALL BECOME INVALID. 1) Permit requested by: (Ownerlagent/prospective owner): ,���i � G� �/ ��� / H o m e P h o n e: 3� E�.2 �. 2�%, f',� A d d re s s: !l r�' Y l � h��.4 i// ��[ Business Phone: _� �„✓ 6o.-n �V� 2) Name and address of.current owner: �ft'�r �.Uc�.1i�w 7 0� f�l� G- ee� �� // �� � o �. 3) Properiy Description: Lot size: Township: ��� � Su Directions to the property (Including road names and numbers): � Lot # �i%`// �.,.�, G/ � b � �P �` �.t, y1 l�-h � w O. ��� Gi���', �o S�a.�,s ca ,�,v 1 P� ��� Af 3`,of.r.s cqrt/ X.�.-f 4� Proposed Use and Structure Description: answer each of the following questions: � a) Proposed �, Existing _, Type of Structure: �� e.� � 1'% . Width: �� ) Number of Bedrooms: Number of occupants or people�to be served: D�v� c) Basement: Yes_, N� Will th re be plumbing in the basement? d) Garbage Disposal: Yes , No � ��� ��_ � p�-O 3 ►��3 � d- ..Se, �► Depth: � d 5) Water Supply Type: Private X(new � or existing�, Public . Community , Spring _ _ Are any wells on adjoining property? Yes K No _ If yes, please indicate a�proximate location on the site plan. 6) Does your property contain previously ident�ed jurisdictional wetlands? Yes_ Plo X PLEASE NOTE THE FOLLOWIfVG: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SI;BMITTED W1TH TFi1S APPLICP+TIOAI. ➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARFCED. ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE ST.�fCED OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBLE FOR AfV EVALUATION BY THE HEALTH DEPARTMENT STAFF. I hereby make application to the Person County Health Depa�tment 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 becorue�invalid. _ � ���, � Owner or egal Representative � / 3 c� 3 Date PCHD, rev. 06l27/02 � �����,�,� ���� �� �..��' � � ���� I��.�a-� �.�.�.���.�.11 IF� ��,.Il-�11La � T� H Pli�� C� � '�:t�r c.. �" � S�u.hcfi�vi�i�ia � Pfa;a��•c'S��ctio�r�i�-Lot � . �pr�veffient P�r�t Permit'�Talid for �! �'iv Years. l�Tct �piraiaan �� Type of Facilitg: ��� �— # of Occupants # of Bedrooms Proposed Wastewater System: _ i�i✓a Propos�ed Repair: /�i�tso�✓�i�t Perinit Conditions: New. ✓ �ddition ed I�aily Flow � �7a$er �upply _��� g.p.d. •- l � - ,,� � Qwner or Legal Representative Autharized State Agent: � The issuanco nf this permit hy the : _ _ _ applicant�property owner to in sure that all Person County P�lanning and� Zoning and Building Insgections requirements are me� T� Xmprovement PermIt is subject to revocation if the sita plan, plat or the inteuded use changes. The Improve�emmt 1'er�it is not affected i�� a�cLange in ownerahip of the property. This permit was is�ueai in compliance with the provisions of the North Carolina `Laws and Bules for Sewage Treat�ment aRd Dis,posal S`sstems' (15A NCAC.I8A .1900). Neither Person Couniy nor the Environmemtal Health Specialist warrants that the septic tank system will continue to function satisfactoritX in the future or that the w�ter supply will remain pota6le. � � �Ai1tI1��8#d0II $a ClDY13�llC�'�a�$e��$e�' Sj�S$�llH �ltequired for B�taldi�g Permit) . * See site plan and additional attachments (_ j. Propose�astewater System: /�►i1��i��/���Z° � Type Wastewater Flow c3(o0. g.p.d. New Repair ansion _ So� I.'rA� '� g.p.d./ ft 2 Type of Eacility: � Basement _ Yes No �Tast�water Sy�tem Reqairements Size: Septic Ta�ic: /dGl� gal ,. �p Tank: l g�l' Grease Trap: gal field: Total Area: � sq ft Total Lengt�n �C� ft 1Vlazimug�'�rene3� Depth � in�"� eh Width ,� ft lY��ninaaam Soal Cover: � l� ixn Minimum Trench �epazation: y ft Speeificatioias: �b� _ Distrib�tion Box � Seri�1 Distribution � +1316.le�i� l./_ `� ^7��t n n.r ...�,..�Sr,� A�a#hoa-�aed 3tate Agemt: __�!� Perrnit Expiration Date: — �� _ Pressure Manifold r� Date: --� —� The type of system permitted is Conventional � Innovative Alternative. I accept the specifications af the pernut. ' � - �,,� � . Oevnerl�eg�i �tepr�sen�ative: Date: .�`� �� � PCHI�7/30/2002 �.�,�,s� I�I��.��� ������ IE'�J.a.a�n�c-annau�rn.�yta�tn,Il IHI m�.n.iEna SITE SKETCH Name f 9�� Tax Map #_��� Parcel #� Subdivisio Secti.on/Lot# /-�!v - D� Author ec� ta.t gent Date Syste��z co:laponents represent a�'iproxi�nate contours only. The contractor must flag the syste��z p�ior to beginning the iristallation to insure that propergrade is maintained __ _.___. .-----_ ____-- _ __._____ �._.... . _ ___.. _ _ --- ______ ___ ._- --. .___. _ _ _ . _. . _.__ _-- - / ,���3.% 'Q d / ��65� �O . • ti iv � _ti� . �tiL , . cG�ee R 133� yV '' S� �b��� R M �P� ,� 6 � .. , a :1� 52�� 22 �e p� N1Zp . N�o .., 0�°� 25 a� o b � � � a�a�5 � N� �... N� 58 96, � �� -- ^'�`�..E � .y . eNF W, a5 p5 � I � 7'R�—c. �d �. ��:� un/n� dGT'i �� ✓� � �✓�✓c� � �ys-r�1 v� � � �. �a � 00 � t)o . ro�op O rn�� o N Q Aooa t`j O ���� � � � ��� , 095 sC� . ft. fxcludir►g f� W � aT��9 - �:��,-� _ _ �v� � :N• n � � ��� � 7 . ���i�. �y�yJ � `'"r� � . � � ��J .� v � � �iZC3.YS'��I��?33� �al3�� ���� � - ���� �'� �A�s • rr_ i1 � (�7�Gttiu � i. - � _ ,,R �.� �,,;� � .�.r..� �i � �'U1��! =�i�`�n �(t ' � � -�': ,�'r+, I r; ;- � ;� � s � . � . � . C� �E� �'�'�I Ol'i � ��D`�1�� . ' � - ' • . m T e tn Accor�ance W�ih'Tabi�e Va): . i. !� SY� YP C . . . �g �N tapg • BE�I INSTAL"LL� It�f C��FstIAMC�- .1MTH APPLiCABi..E AIORTH CARQL.�KA [�EAtEItAL. �STATUTES, -RUL.�S ��1� SE�IiAiGE'.'Fi?E�i.TMEI�[T' AND i�iSPO�►�.., . AND ALL t�3NDITiflNS . OF ;'Ti3� I�iPRQ�Ei�IT� �E�tI' Ai�ID. •CONS'F�!lC�1�i� ' -ALI'Tf10 �N� � ' . . , ' � (� Y� , � - 'Z—�3 � � � . � � -�na� s� �� � � � . ���� ,. .- . - -, . � _ . � . � � �� �,.�wf � —�— �� � .� — 7—�3—� — li,s� B�: -- � � . - ;� �� ' �T���t . . _ . .�.�.--�/\ / (/ I�1QP�`e" "�3i` �`3« I �' f /z (9t� � (0 _ (o t� � 9' �---� �'l/�r�ee/1 , � �� e _: f�a�K / ,,�, 7Sn � � L Z; Ro�K , Z�' ��.��� = � _(,U� �t� �� � : �,,,`5�r �r � b_ _�r � , ��_ � �`'`'"'� . � --- ---- _ --- -- - _ S � . Z-.Z3-�<-� �-��--�� ��(,t�s � � ��� �fis �� � , _Sfi� i `-�Z wl r� �e�� --------- - -__ _ __ FC'�-ii3: �v. 0�;2n�C2 � . ��C '�`� ��EE�'�it3i� L'��i.�SS"�' ='i"� �.01°�'� . • - . T� 1ViaQ � � � � F^� � � - g - . Sys� TYPe (T�ie ��� . c�un�l,�,�ic� s�n � . Addr�s�ca�n � �S�tza� Lcit # � _ . . . �, . . — i/l�c.� ' �� � � "l �L� . . _ d Co� cv-eC� Ltd� a�' °� ti'�' . - . _._LJ �.. ']i�i�/A�1 �.1��.��" ���.� ��i.. � �'= .�—r- c� � �T�'�� I���-�-�-� -t.,.-�. ��-�.I� �3C�.�.71-�� WE�jI. PE�'�' P��E S�E 1�'�'�A� �'�i ���t W��. S� Lf��OIT� T�x 1lRa� #: ,� 3 � Parcel # ^T' J � 'I'owns�aip g��]�� �i-o ��m i l G rc r Subdivisiomm: IJ I (� Seaxaom: �� I.oc�io�a: J� U. P� r �n �� � . �'�,t ' r; )�� ,�. � i . a • • • ��s�.���a�n�. �ur� � ��� � �� Site Approved bp �� S�� Grouting Appmved bp p � `� �C. �ell Log '° ` �'(2���� Well T ._ .A:ir Vent � Hose Bib _„l Concrete Slab �� ,...i ► � . � • , � , � 1 �. � . , • , \� I ' � � ,.:.'�� , � . „ ��, il � . � � � � - . � � , ��� ; { :�: . � , ' t i� �� '•_ ir �/ s,� , �`� - I: r ,F �. � - �: ,�, . �'± . - �°5e� AttaC�he� �ate S�tc3i'� WeDs must be 10 fest from prop�rty liaes. Wells must be 100 feet from septi.c systems. � Wells must be at least 25 feet from anp bwlding foundation. -�n5�.11 i1cW Wc.0 G.5 s6.a�n. Co0' �r��-► 5cp�ic! �S`Frr,►n l,on�c� • �i0� %om i iqkt DDit d� O�c� hc�-d Powcs� 11�cS � ' (1(�u,��a�o �"Y a-ba�don mc.n,f p F old W�i1 b�Fo�c � O�.�Y �o����� °� b�� � ns, O P�,�,p o�-t � re Ma�� P►um��� rev. 09/07/Ol Z C��i'i'n� t� 3 F� �I W�Ccmc�►� , .�� ���� �� _ � '���.:T���:. � n�-�na-�arau�na��n.�am:� ����.Il�.� Owner: �� Location: � Subdivision: Drille.r ID # ,�, Com,���ny N�me � � _,� D�t�e Drilled � � Grout Log Tax Map �� Parcel # y�-,(� Lot # Well Constrnction Distance From nearest Property Line (Minimum 10 feet) Distance from Septic System (Minimum 60 feet) Total Depth: 12� ft Yield: _� GPM Static Water Level: �2� ft Water Bearing Zones: Depth�rS ft{/[2lu ;ft ft ft � � . �., Casing: Depth: From �_ to �� ft. Diameter: CZX� in Type: Galvanized Steel � Weight: Tluclrness: � Height above Ground: �_ in _�� Drive Shoe: t� Yes No Any problems encountered while setting casing? Yes o If "yes" give reason: Gront: Neat: Sand/Cement Annulaz Space Width Method of Grout: Pumped _ Concrete GraveUCement inches Water in Annula�ySpace Yes No Pressure Poured �� Depth _� to � Ft. Materials Used: �� �� No. Bags Portland cement ��: �,f�.i Weight of 1 Bag s� Pounds If mixture (sand, gravel, cuttings�) — Raho to ID plates: _ Yes _ No 4 x 4 slab _ Yes _ No Liner: Depth: Date Installed: Grout: Installed by: Drilling Log Location Drawing From To Formation � % �t r � Q rn�..• �c �S t r�i:ti � 4 `aY��� G G �� I hereby certify that the above information is correct and that this well was constructed in accordance with regulations set forth by the Person County Health Department. �� ' Signature of Contractor Pump �P P�P ft Static ID # ,���-� Date ��10 � C% �i Pump Installment State Pump gpm I hereby certify that this�Cfmp was installed an� the well head completed according to the Person County Well Rules in effect on this date and that a copy of this record has been provided to the well owner. . pwnp Installer Signatur �_ ___ ____ Date: PCHD rev O1/27/04 Barnette Well Drilling Inc � 3�6 598 9275 09l@3104 08:49A P.001 ., .. . . - . . ..:. . }. � .. ...�. . » .....,.. .•• - ,. . :, � _ • s -... •� - . �. • - ... • � =.. . -.: :r ,. � .,� _ • � ��„����•�• : � , _� �i � � J I C�i\ li�i��+��/K 1. WF.LL LQCA jWtarest 2. Q�ER: ._.._ the !� oa �adc '/"tC G( 3. I+D17R�5� �. 'i'CPOGI�Pi�Y _ �raw. slape. hillb�p•'�'�Y• � s. us� eF v��u: �c�--'`��'o�`�: �-. r_ "!'0'T �I. D�riTH:.-- ».�-.��DIAME'I'ER' —�'� ��SING i�.'vIQ�"EJ. � � • . �1 � �. SGI'MM��� lY{[lLi+iviLr• �� L'?+�'� �s ot cea�cnt �.,^� � baqs of cemea� r„_ �Ccia. csf wa�er ,�� Y�. af �azu3 (- t , a�� �' �1s. o�' wac� �,� �t �� � � ���� n ��� �. ��.��oo �.t��c�.rrc'c�� xw�r�`Rsn�-- . �..�2., . � �,dra�ag�e No. ,�(r D[tiGFiliD� �a � det�iled alcesc� c�. arelL �oori�S � d�� d�� an� dia- et ot' �Cte� t'd�$ � the wcJl. $[avel rval. imt�als of c�iaS ��ns. and ths �ztl tyrirt� af 4I1 � �e�. � . � I do her�bY C�r�p' � ttbs we1l a�; rew�! is trua �sd cxaet. . �J � � At� g;gn,aa�re of Caatrictor ac AgCat skebeta uc� t�te r�verse of tk� sh�'t. �tow�8 the 3tx�ec- WSLL I.00.A►'IION: ti�cax a�d d�a�oe v� th� avdl tie at �� i�A u�Y ���a �°�� �uc�a as rpads. iuL�s ��' �'��y �� St�te E�figh � it�d ideatlfl�� nucubtrs. ` Submik osigyns! to the Div3�or_ aR Wat,�s' 9u�titY� � C°PY t� thr f,?nilrx. auci an� co�y to t�� awaet. GW-30 Rew.,acd I l98