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A35 44Apaiir.ation Date: I �v� �lmaunt �ald• Reca�pt �: ' ���� �� �I�I�..� �I� -- . ������ ����,�,..�.,..���� ���.��. Tax flAa �: �� [�arrzl �: _f APPUCATION Ft3R SE3tVIC�S � �'`���., IF T'HE INFORMATIOM IN THE APP�:1CATlOi�l FaR AN IMPRO�lEAAENT PERMIT 1S INCORRE�'i'. F:4t.SIFiE�. CHANGED OR THE SITE IS ALT�RED THE3N iHE 1MPROVE�IIENT PEiZMTf APID AUTNORIZ�►'f60N TO . CONSTRUCT SHALL BECOME INVALID. � 1) Pertnit requested b:(Owner/aget�tlprospective ownerj: Doa? � U� y�� Home Phone: �� Address• � ` � � Business Phone: 9/�i - 55'3� `//z 7 �� 1.,.-.,.. /IL'_ 2� ��3 2) Name and �ddress of carrer�t ownec �A/�t 3) �roperty Description: Lot size: Tawnshlp: Dice�tions to the property �Induding ro�t names�and )� # 4) Proposed lD�e and Stzvcture DescriptIon: answer eaci� af the following q�estians: a) Proposed _, Existing �, Type of Strucbure: f�{D USF Width: � De�th: b) Number of Bedrooms: _� Number of �pants or people to be� sen►ed: � - c) Basemen� Yes No _ Will there be plumbing in #he•basement?� d) 6arbage Disp�Yes . No ,�, _ 5) Water Supply T�e: Privabe �, (new or existing_ j, Public_, Community� . Spring � . Are any wells on ad�oining praperty? Yes No _ If yes, piease indicate app�aximate locatiori on the .site pian. � b� Does your property c�ntain_previousfy idecrtified �urisdictional wetlands? Yes No� PL�ASE NO'TE THE FOLLOU111NG: ➢ A PLAT OF THE PROPE�2TY OR SiTE PLAiN MUST BE SUBMITfE� W17N THIS APP�iCATtON. ➢ PROP�tTY UNES AiVD CORIdERS MUST BE CLE�►RLY MAR6�D. -, 9 THE PROPOSED LOCATiON OF ALL STRUCTURES i1AUST BE ST�D OR FIAGGE�3. 9 THE SITE MUST �E RE�►DILY ACCESSIBL� FOR AAf EVALUAT]ON BY THE l�E.4i..Ti-i DE�ARTMENT STAFF. I hereb� make appiic�tion ta the Person County Health Department for a site e�aluation for the an-siie sewage dispasal system for the abav�described property. ! agree that the c�ntents of this application are true and represertt the maximum facili�es to be piac�d on the property. i understand ifi the site is aitered or the intendeii use ct�anges, the permi� sfiali become irnalid. � � „ or �Le�al Representative � ' -O�. Date PCaD, rev. 06127/02 - .����5� ������T ", � � �LJ lV� �� 7E�m� na-am� �*�'* �as�m�l IE-7L��.11�I�a 5��. ��' .TC� Name �uwov� �:�� �;s . Tag Map # � � .Parcel # u `� Subdivision � Section/Lot# � o� >� �a Authoriz d S te Agent � Date System components represent approximate�contours only. The contx beginning the installation to insure that pmpergrade is maintained 2� WeJ,\ � •� . � r ci �r� _ A-:� �. �- ii-�Q�� S��C.. Y�O^�l�C C.JI'�L. 07 t��'c/�Q h J '� 1 CtiD,S • J SCil.�e: 1�oa. ko ScuQ.¢,.. ��S��-1S 0 � a ; � � wQ����" ` %�./ � � S k �,J� ZO� � ���-;� oca.p- � � � the system prior to r���� j�c' � L L PGI-�D, rev. 09/12/Ol ���,�� ���.� �� _.= ������ 1L:s4aNa��1TMn mrn �?aZ��.� ��.ffi.��� WELL PEItMIT P�lSE SEE ATTAC�iED Y'Y.AN FOR WELL SITE LAYOU'S Tax Map #: � J5 Pazce1 #� Township Applicant }�,.;��� c �� �;s Subdivision: Section: . Y.ot Location:� i �4„�r,Z � S�-f 1't'1�C�f��s 1'11�'1 t' J T�e of Water Sun�lv: �Individual Community Public Itec�uirements• Site Approved bp C' -� ► n��� Ja Groutin.g Approved bp �� �'� �' s Well LogC��� 1- 2�--�3 _ Well Ta.g_�-Ss � � Z-� -a3 �1L �C'ilt iy,�c .S i `�"v3 xose B��b C�-ss � - Zt�-� Concxete Slab s'' ��cna,,..�a 154 �11 �,�)�1 0.-� 1^Z4�._�+3 .� �a.� ��.� Z�,. :�,� Well Driller. :� <.N� U � 1/ ����1. Well Approved By: IDate: '�See Attached Site Sketch'k* Wells must be 10 feet from propertp lines. �_, G� Wells must be 100 feet from septic systems. Wells must be at least 25 feet from any building foundafiion. � Other 17' ►z� � c-s� �-�-� 1� ��'}�w PCHI�, rev. 09/07/01 Barnette Well Drilling Inc � 336 598 9275 01127/03 07:06P P.001 ��e !Z ; �R, � �� .�---• � ,`?� ��� �� � ���;5� ���� �� . �. ! ``�`, � � ��T''�'° �' � �� .�G� x��.�.�-��.,��.��.n �.��..��� ' D�Oc� Da�i �,�� .���.,s --.� �wner: � Locati4n: �_� Subdivision: Gr�a���,og Tax M.apfJ,� ;�; Parcel # � Lot � Wcll Construction D'z�tance From ns�rest �'raperty Line (Minimum 10 fcet) . Uist3nce from Septic System (Mini�mum 60 feet) _ ' . Total bcpth«`� f� YieFd: �_ GPM Stati'c Water LeveI: �_ � tt Watcr Scaring Zoncs: Dcpth � i� �_ ft� ft ft � � ��� c�: �cptin: �rGm r to _��._ $. Diametc[' �;,! %�� in T�rpe: Galvanized Stc;cl' - . ' Weight Thiclrness: �� Height above Ground: � in Drive Shoc• � Yes No Any problems cncou�tered �uvlule setrin�g casing? Y-cs-�t Nv If `jres" �ve �`'�eason: _ Grau� _ _ Nea� SaadlCeznez�t Canere'teV Gravel✓Cet�ent ---• Annuiar Space Width izxchcs Watcr iva Annula�r Spa�cc�-�. Yes No Method o£ Gxout: Puu�ped Pressrtrc Pour�d- � �epth to �t Materia�s �Jscd: No. Ba� �ortland cen�tent Weight vf 1 Bag Pvunc� . I£mixt�uc (sand, gravei, cuttings) - Ratio to _� ID plates: _ Yes _ l�0 4 x 4 slab _ Ycs _ No . D�� �,� Locatian Drawioag I hereby ce�tify that the above infomlation is conrect and that t�is well was constructed in accordance with re�uiatioA: set forth by thc Pecaon County Health Dep�nenti l Sig�aature of Caatractor _.r,�'��H �1.�� Y� #� Gf �f Date ��1• C' . . . . n.-� _._.. o� ��cm� Barnette Well Drilling Inc 336 598 9275 01/27103 07:06P P.003 . ��� . , . . � �aafi � � . � • �e�o� a��� $�Y �� � P.O. Boz 2�78 ��• N.C. Z78�6-+Ob'78 � m ;. vv�.[. I�`.�'TiOl�ic �„�.iT� i7� e�e tieea�loia ' 2 OW.s$R: �1 3. �iORE..�: �. t040t`diAt'HY : �cs�r� :�P. �. d�►t �, tJsa os w�.: c � aA'r�: �' �DGMLrTS'Rt ""'--- �S. '1'd�'+t. D�:'� • 7. �.�STi�tG Ri�+tOVR�• � ' �'f;/ � �/c. _ ��.--- 8. �S�alttNd 1r1A'l1Gtt11[.= ��� • ���' � �a1s, ut qra,Gsr y� a� U� �, ot �vacer i� o� �» � .�.� ..�..�.-�-- --� de. � � d�r �t �6e�ri�� t�#= � � ��e11. � ' e� ds�t+em� r� �bw xT� tYpn a� � �t � . t ! do riee�by v� tbar ttds.rtll __._ ss ave sn�a �• .� ' � /' " � aat�d 7 Si�aa�u� di Cam�'x� - �R R��, � ot tMs sbeser. a� ���' VVF�.L Lb�:A'liGNr tl� a� � at' t�s w�l to at !�t �ro i�i cwaeb� �fe�aCe � _���'�-t��►�`�smte�, w�► ��p�t eo tl�e Q� atN�e'� C"�Y• o� c�ap�► Oo t�e DKtller a�d aru cvpY t� tse orrne� : -- GW-90 Rtw'�r4 1 /g8