A35 41B�. . . •
�,pplication Date: ��' J �', �" -'
Amount Paid: � 06 . U O
Receipt #• 3
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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
�
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I��.�a-� �.�.�.���.�.11 IF� ��,.Il-�11La
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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��.���
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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
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�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� '
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c�un�l,�,�ic� s�n � .
Addr�s�ca�n � �S�tza� Lcit # �
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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 ��
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�°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�►�
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� 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
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3�6 598 9275 09l@3104 08:49A P.001
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,�(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�.
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g;gn,aa�re of Caatrictor ac AgCat
skebeta uc� t�te r�verse of tk� sh�'t. �tow�8 the 3tx�ec-
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�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