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A35 73� H O a a W � a � z �`�z4-`i� .c Improvements Permit (Established/Recorded Lot) I_ Reinspection of Existing System (Loan Closing) Improvements Permit (Unrecorded Lot) Permit (Mobile Home Replace) Improvements Permit (Addition) Repair/Replace existing Septic System Permit for New Well _ Replace Existing Well 1. Permit requested by: owner/prospective owner/agent: I Po�� v�� c.JA � a. Address: I-� �ASS� L-� �8'0 ��a o►�K�� e,D "� �xh„�- ,� �.� c_ � �s� 3 :ome Phone #: � I o S"5�i -� o� � usiness Phone #: Name and Descripti 7. Dimensions or Proposed Structure: Width: 8. What type (if any, additions, expansions, or replacement is anticipated to the structure or facility that this sewage disposal system is intended to serve? of current owner: 5��e�� 15 9. Water supply type: r��( �r, �0 0 � C� private �' public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No� If so, identify location: . Lot size: i�i � r� Tax Map#: b 3 S Parcel#: ~7 3 Townshin: � ��,�0 s ol G �� . Directions to property: State Road #& Road f ames,g �tc. (�t� J� Crc2ou� ��brtcl�' � � Number of occupants or people to be served: 02-� 10. Type of structure/facility: Proposed: DExisting: ❑ Type of dwelling: House: ❑ Mobile Home: Business: ❑ Tvne of business: umber of Employees: - umber of bedrooms: � b�Y �� `" �`"�'p`� ,�,, �-b s�ud y arbage Disposal? Yes ❑ No C� asement? Yes ❑ No ��so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the Person CoUnty Health Department 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 become invalid. I understand that before an Improvements Permit can be issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of the site by the Health Dept., this application shall become void �nd all fees paid forfeited. Signed Owner or Authorized Agent Perr�ii� IssU�d ❑ Signature Permit Denied ❑ Plat Observed ❑ Date FACt'ORS-STIEEVAL.UATIC>N ARPJIl. z AREA2 ': AREP:3 . <:AREAd :;:. .. _ _:: , I. SLAPE (%) S S S � S PS PS PS PS U U U U 2. SOQ. TE7CTURE (12-36IN.) S S S S (SADIDY. LOAMY, CLAYEY, NO7'E 2:1 CLA� PS PS PS PS U U U U 3. SOIL SiRUCNRE (12-36IN.) S S S S (CLAYEY SOILS) PS PS PS PS U U � U U 4. S011. DEPT'H (IN.) S S S S PS PS PS PS U U U U 5. RESTRIC'I'IVEHORIZONS(IN.) S S S S (L4IPERVIOUS STRA'fA. ROCK) PS PS PS PS U U U U 6. SOILDRAiNAGE/GROUNDWA7ER S S S S (EXTERNAL R INTERNAL) PS PS PS PS U U 1J U 7. SOII. PERMEABiLITY S S S S (PERCOLOA7i0N RATE) PS PS., PS PS U U U U 8. AVAILABLE SPACE S S S S PS PS PS PS U U U U 9. SITECLASSIFICA710N(SEEBELOW) SOIL SER1E5 S-SUITABLE PS-PROVISIONALLY SUITABLE U-UNSUITABLE RECOMMENDATIONS/COMMENTS : SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope patterns, etc.) C:WNIPRO�DOCSIAPPSEC.SMFINANCE.PC r � PERSON COUNTY HEALTH DEPARTMENT WELL A�SEWAGE SITE, LOCATION IlV�ROVEMENT PERNIIT Tax Map # ?j S Parcel # Zoning Townstup p o .S � Owner/Contractor Location/Address C�o �o E � � -fv .5��'C Subdivision Name� A 0371 t . L� Date � o,F' � 3 nn� �lvk D�� r�'v� /��Q ! r o f S.R.# Lot# Layout As Installed • �- � � �L� � r t '� i�'�1( N� � f/�% �;` S, ; s � c��ble � � � h�h:� �►�e � . N P�,J Ne rv-r � � ��. � � c � " W�� Q o W t�,-e �-6�e�.e w� s�`� P ,� � � �.� n �,'✓e 1nj i (�,Q wi � � r �� I . Sy �� - U � - � .��y SEWAGF. S��STEM SPECIFICATIONS Repair Lot Area ! L��- Size of Tank �l �s�i� 10Lill � SFD Mobile Home � Size of Pump Tank n!!I3 Business # of Bedrooms�_ Nitrification Line �� r `�'.1J,,: _ Max Depth Trenches Nl � Permit Void after 60 months. Permit Void if not in compliance wlth zoning regulations. Permits may be voided if s. Well and Septic Layout by Comments: �, — Date – (7 - Installed by_��G��_Approved by i WEI.L SYSTEM SPECIFICATIONS ividual Semi-Public ublic ite Approved �ell Head ove �r ' g Approved Comments: �� IRequired Slab Air Vent _ Lo� ell Tag Date This report is based in part on information provided the homeowner or h�er representative in the application submitted for this permit The environmental health specialist is not responsible for false or misleading infocmation contained in the application. The environtnental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resuited from false or misleading statements provided to him in the application. Neither Person County nor the envuonmental health specialist warrants that the septic tank system wiil continue to function satisfactorily in the future or that the water supply will temain potable. c:4lmipro�pemut.sam O1/95 rev.1.0 ORIGINAL Application Date: � .�v Amount Paid: � � P2ecaipt #: U �� = � �= �� a�-��,.-,.-� ��a �--�� a�� f�PPLIC,4TIOIV FOR SERVICES Services Requested ❑ Improvements Permit (Recorded Lot) -$200.00 Well Permit (New/Replaceme Improvements Permit - $150.00 (Mobile Home Replacement/Addition) Repair/Replace Existing System Pertnit Tax f1Aap #:,� .� 5 Parc�l #: �� !/��s �-----._.__ -- -- --_---� ❑ Construction Authorization for Septic Systems- $150.001$200.00 Permit Revision Fee - $75.00 IF i'HE IfVFORMATIOfV !N THE APPLICATION FOF2 AN IMPROVEMENT PERMI� IS IIVCORREC� �ALSIFIED CFIAiVGED OR 5HE SITE IS ALTE6aED THEN TF9E IMPR�VEi�IEfVT P�F�M9T AND �►IDTHORIZATIOfV TO CJRISTRUCT SHALL BECOflAE INV�4LID. 1) Permit reques�ec9 6�y: (Owner/agen�/prospective owner): �LcJ/�-�/` Home Phone: �%� - � �� "� Address: Business Phone: ��%�� _ 2) f�ame and address of curren� owner: (,�l/a��i r�r� �S� �-�- SS?v /-1�✓r4 U1-Jlt � E�/ / . ,� k �orr, 1� C � % S �'i 3) Proper�y Description: Lotsize: Ia,.r,�� Township:�J�dS�� Subdivision: Lot#�S"� � 3 Directions to the property (Including road names and numbers): "lr-?/�C� c'Huc; �r��<r 2i� r-i�c Ti-rc= w��l T.. �'1T�1 i�7��c Rn i��,��,il i-FT l—c %�tC TNC Ic STof �lG-rl/ Tu�Qi'1/ %f o��l /J'roRT�� y"G I�/�'1 G�o Tv J��.l(rlNiyl/c�ICl�. �O/CC %�"� /�I �pSS {7 C�i: D/-�1C C-�fo�'� C Hu/CC id /ZD, i t�%1� F�F Drv pAK G'r�oUc= �}� C-�, To ��-✓R UAI<LC-Y Ct7PR�u-.J� 4) Proposee! l)se and Structure Description: answer each of the following questions: a) Proposed _, Existing , Type of Structure: 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 _ S7/C�4�G-7�-T c^�n; To O��J ✓h7 Z�a�1� ,��k� l��KE L�(p��'(�4�) �� ✓-1P2lLc�( � Width: Depth: 5) !I!later Supply Type: Private �(new ,/ or existing�, Public_, Community_, Spring _ Are any wells on adjoining property? Yes_ No �- If yes, please indicate a�proximate location on the site plan. 6) Does your progoe►�y contain previously ideniifiec! jurisc9ictional wetlands? Ves_ Plo�= PLEASE NOTE TFEE FOLLOVUIRIi3: ➢ A PLAT OF TI-�E PROPEO�TY OR SiTE PLA�1 MdJST BE SUBiIAITTED WI�'H T�iiS s4PPLICATION. ➢ PiZOPERTY �II�l�S AND CORMERS MUSf B� CLEAR�Y MARFCED. ➢ THE PROPOSED LOCATIO�I OF ALL STRUCTURES MUST BE ST,�KED OR FLAGGED. � THE SITE MUST �E RE,4DILY ACCESSIBLE FOR AN EVALIDATIOM BY THE FIE�►�TH DEPARTMEiVT STAFF. I hereby make application to the Person County Health Department 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 become invalid. �?/� =�e<-- v �/ Owner or Legal Representative 3 3 ' D� Date PCHD, rev. 06J27/02 H � (� � � �i � � � S -� A G S C• � � � �Z � � � c'\ �. � � � � � r � r � � \ 1� o � � � r r 0 R� � � � -� � � �I � m � o � � �; � � s � � o�o � �' � a �� J � � 2 �I � � _� ` � � � yc� � � �� o J � d � `'' � � y �,� � � � � �U � Z, � D � � � � n�� F � — i � � o � yT � � �� ` n rl ,`� r� � � Application Date: �► •�-�o Tax Map: 35 Amount Paid: �► C� Parcel #: �_ Receipt#: � � `—��. ) . f _ �� ' � � � �� ' IL.. xc��n �-� na ��-� � a�a �.rn. ll I�ZI �+.�a..I1 d7E a � Applicatioa for Services (Septic Systems and Wells) Services Re uested 0 Improvement Permit (Site Evaluation) 0 Construction Authorization $200.00/$300.00 if> 600 d) (Fee is de endent on the ty e of Mobile Home Re lacement or Buildin Addition 0 Permit Revision ,�,:�^,_^,4��«e :.�?��-.��iredl $75.00 � Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 1) Services Requgst� d by: < �< Name: GJ�/( I� G�� l�7'l C � Address: V� p,�C a o ✓o� •C'. ❑ Repair of Existing Septic System No Charee Phone # (home): � Q � � � � � 7 (work/cell): 5 3 – � 2)Name and address of current owner (if different than applicant): Name: • Address: 3) Property Description: Lot Size: 1 R C Subdivision: —' Lot #: —' Address and/or directions t Property: p� 1< Cg �^e c�� n,t � zi�1 G 1^� v 4) Proposed Use and Type of Structure: Residential Business/Type: Other t/ Number of bedrooms / Number of people served (seats/employees): Basement: Yes No (with plumbing: Yes No _� Garbage disposal: Yes No /� �� 0 � �t� 5) Water Supply: � Private Well ►� (Proposed Existing � Community Well: Public Water System: Are there wells on the adjoining properties? No Yes � (please show location on site plan) Note: A comp[eted application must also include: ➢ A pladsite plan of the property that shows property dimensions and the size and [ocation of all proposed structures. ➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated. I am submitting this application to request services from the Person County Health Department. I understand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvals shall become invalid. � JZQ�' � l Z j� Signature (Owner/Legal Representative): �'�� Date : Z' a� 10/OS Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) �� . � i � ''�r+1,� � � '�'1� � � � .�. 'V � � ,.tL..id�ll.�''717idm7L'iL.]�.�✓3i�l.�at1i.11 � ,tE"✓a�.��+� �uilding Additions/ lO�Iobile �ome Replacement� Tax Map #:�_ Approval Requested for: Parcel#: �73 Mobile Home Replacement �c _ Building Addition � Applicant Name: W��\ � c��, l,�h i-� P�� Address: " y� �A1��c� Cn1�.le. a"�ci � x � ►.�� ls7y � � Phone #'s: .�iq - ( o �1 _ 5� - i�xlc� _ ,i � � Pernut Located: �/ Yes No Installation Date: �I- ��-�� Design �flow: 3� (gpd) Current Contract with Certified Operator on file (if required): N�� Water Supply: _�_ Well � Public or Community Wastewatex system shows no visual evidence of failure on: �7' a-�� , t (Applicant's signature if site visit is not required) � `� Additionll�eplacerri�nt Approved �1►�.�a �o�.. Environmental Health Specialist � 11/15/OS �lal�o Date s �� 'L1{ � �� ,,,, �.^ � � �� Gan.-�a��*,rs��.�o.�. �LL��.II..� ' • - , r �1?( ��i;(J ' ' cl:I'"C�� ! S'GTJ.�i�l':I�ti'1Ql1 ,� � E��:�,•4��S��.�i,a,►�i:��Lo�'t r ..��r��tioC1 �P��# . � � S �fem Type (In AcxaRiance Wrth `Tabt�e Va): � "� Y . TH9S S1rS'T�PVI !-i�4S• �EIEM !AlST.�LLE33 d�i CC3NlP�1�►PICE.:1Nt"iH APPl.�CABL� NOR'6'1-1 CAR�3LYNA GEIVEF�►L S'T�4TUTES, -i�UIL�S �t3� SE�IAGE "F�EAT�IiE�1iT �ID F3t5POS�., . �►ND ALY. CO�II�iTiONS .,OF THE !lfilPY��E9U1E�9T 1PE�1'3' AND. �CO[dS�UCTtON � �&tUTH� 'p'10 , - ' • � . . .�.. ..' � � - �Y�J`�� ' : _' - . . - �-' l� ..:Q �. . ' . �. .. i .. � . 'Authorczed State Agetrt • � � . ' � � . .' _� � � � Date . ' li�s�alled . f 4 �. : , • . . . • Date• �� '�`� �� . . . • _ . �' b . r rr _..._ ...._._ 30. �-�-�, �1 �' (; Lt�s 1� �� l �(;s�`'►''`� r�K � � • - L; a,� • �� c�^�' ' � �� _ ,�, l�eY rc��. �,�. a �iza�c� Application Date: �� "� � � � Amount Paid: � � � _ Receipt #: Ff,Z 2 4 � 6_ e.�-� Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 Qpd) I1 Mobile Home Reptacement or Building Addition $150.00 (if site visit required) Well Permit (l�iew/Replacement/Repair) $ 3 00.00/$ 200.00/$75.00 �.,�� ) f . �11.�� `l.l'1 V Taz Map: � 3 � ,,�.,; ►•;s-.t" �.��,�� Parcel#. �!� IEa�nvna-ogn uttn�sn�£acIl 3H[<-�,.11�.lE�. tion for Services Services Construction Authorization (Fee is dependent on the type of Permit Revision $75.00 Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Inform�tion: � , Name: (�i l�� Qm + t�a-n o) R i.l �'1 �'�'�i t 1 a Address: Sl�O Uq Da X l� f� �ox e r� n�r C a 5 7 2) Name and address of current owner (if different than applicant): Name: Address: Phone (home): 33 �- 5 9 4-� d� 7 (work/cell): 33 6� 58'3 - y`' d Phone: P / MQ � �ax alcc nv�bC/' 3) Property Description: Lot Size: ( I�Ci[ Subdivision: �fl Lot #: � 35 7 3 Add ess and/or directions to Pr perty: Oq � G�'o vC / M� zi o� ?�o O� K Gi`o t1� k� to A�ua o4KPc . ❑ yes no Does the site contain any jurisdictional wetlands? � `� .��ci i� �yes ❑ no Does the site contain any existing wastewater systems? 5 K�� 1� � Q� K'� F�� C/� ❑ yes C�'no Is any wastewater going to be generated on the site other than domestic sewage? � yes C�'no Is the site subject to approval by any other public agency? O yes E�no Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) 4) roposed Use and Type of Structure; �esidential ❑ New Single Family Residence Maximum number of bedrooms: � 3 ❑ Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes C�no With plumbing fixtures? ❑Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: �� X ❑ yes �no 5) Water Supply: ❑ New well LN Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this properiy? L�yes ❑ no 6) If applying for `Authorization to Construct', please indicate referred system ty e(s) �� ❑ Conventional ❑ Accepted ❑ Innovative 0 Alternative �Other �SF X �$ si�/� ❑ Any 1 certify that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, or if the site is subsequently altered, or he intended use changes, all permits and approvals shall be invalid. �� " 9- 3� � �� Signature (Owner/ egal Repres tative*) Date * Supporting docume ation required. • Permits are valid for either 60 months or are non-ezpiring when accompanied by an approved plat. • A completed `Lot Preparation' form must accompany any application requiring a site evaluation. (10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) � � . 4. , ... . � ��:V �� :�:��.�.��.��.Il ]I��.11�]�a. Suilding Additions/ Mobile� gIome Replacements 5 1#: 2?r Address: 5� ./`�� ,�"`� Tax Map #:� Parce L Approval Requested for: Mobile Home Replacement _� Building Addition . Applicant Name: �,�ir ll i 4/yt -�- �c�No�i4 �� {- 'e�� Adclress: �q/1-�.2 Q S R o� Phone#'s: SQ�—CoD6 5�3� ��o Permit Located: � Yes No Installation Date: '/2— �3 —�P�%� Design flow: 3 6�(gpd) Current Contract wi±h Certified Operator on file (if required): vt �} �later Supply: � Well Public or Community Wastewater system shows no visual evidance of failure on: l m�� l5 (date) (Applicant's signature if site visit is not required) � SS/v�1 �cqr �o� f � rj( ($ + Si'�-�;�, ' , Se� b� c,� Qi r! � r+�l� ✓r Y- �cM-� � it � o � �x'; sfi-� K¢ J rc�o� �S��'c��_ �ddition/Iteplacemen� Approv�d y,�, � vv�.� En ironmental Health Specialist lc�-5 l� Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.personcountv.net ��.sf ��..�� I��.daa-��.��.�.]L IHL��Il�I�a. Applicant: �� (liam �hi-��ic (d f (�anda ��i,S,Sc I I Locatic�n: GI� ub LaKc �o�d � m�G ��s m�` ll Ro. � �a- d Ta�x N1�a� � P�rcel # S�unc�ti�i.s�ioia Pli_��_s�erSect�ion�Lolt # ��.K G�OJC -MOUAt Z.iO/� G.f �arK R at (,�hitc- Fc�cc ,l3�x #58� � � C P � � � � Improvement Permit Permit Valid�r Five Years _ No Ezpiration Type of Facility: ��ca5-E i`�w _ New _ Addition Water Supply EXiStin # of Occupants �rr�ax # of edrooms 3 Projected Daily Flow 3(� c7 g.p.d. Proposed Wastewater System: � . Type: Proposed Repair: � �" (.a.��j c. rar►�ctcr- Pi ��- Type: PennitConditions: �n5�� o/� Cnn�bu� c,� Flag<,cd 6y �!>f5 - Owner or Legal Represe Authorized State Agent: Date: Date: �-'I�i�'� �� The issuance of this permit by the �iealth Department in does not guarantee the issuance of other permits. It is the responsibility of the applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements aze met. This Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and Rules for Sewa�e Treatment and Disposal Systems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. Authorization to Construct Wastewater System �Required for Building Permit) * See site plan and additional attachments (�. � l�C�a'� r'� ., � Proposed Wastewater S stem: � � Lary� �iamc�tr �i P � Type� F Wastewater Flow �� g.p.d. New Repair � Expansion _ Soil LTAR: . 30 g.p.d./ ft 2 Type of Facility: E' ti � Basement _ Yes _ No Wastewater System Requirements Tank Size: Septic Tank: � gal Pump Tank: N� A gal Grease Trap: �� g�_s�d� � Drainfield: Total Area: 8as sq ft Total Length 330 ft Mazimum Trench Depth � 2 in Trench Width � ft Minimum Soil Cover: 1..0 in Minimum Trench Separation: � ft Distribution: v Distribution Box Serial Distribution Pressure Manifold Specifications: �� cox� �� be �ic�d cd pvc� Sy5-fc rn. �, rt�.� _, Tl�, or� pn �Y, F� I l�w Condl�ion5 on S�t�i�SKctcti. _ Authorized State Agent: � Permit Expiration The type of system permitted is the permit. Owner/Legal Representative: _ Date: ,� J � � • Conventional Innovative Altemative. I accept the specifications of Date: PCHD7/30/2002 f�1��+�� ' ��.� `L'�1��/ �� • Y V •�� .�4a��A'11 �1l Q� W�iL �� . + U� V i3if-� Vi i Name �Andc�, i-i�55c (1 Ta$ lYlap #�Parcel # �%•3 S n N � •� Section/Lot# � � 3 -[�- o� Autho�ized State Ageflt - . � Date � . � System components repr�se�rt cr�i�prnximate�raorltours o��ly. The c�tor must, fiag th� system prior t� begiasnnsg tha urstallation to insur� ihatproperg�rrde is ma�ntarned ��LC, ��zin.��f' �c,�� ' � ��,u� ,�� f , � �L� I �� 1 � � �(,J ou. td rec�oM r�. c,n,d, - ' (,��iandon�ng olc� _ ��( � a � P��Q �u.� �c�..iorru�.tc QF; n. �� cc•••c•tit- Scale: � l� l� � r �PG�iD, rev. 09/12/01 ��.�� .�� ----= �-�- � � ��- IE��a-�-,.-�-,�,�, ��.�.Il I��.�.1L�I� WE��I.1'EytMI'� PI,EASE SEE A'I'I'AC�]D PI.AN FOR WELL SITE LAYOUT Tax Map #: �_ Pazcel # ��J Township gPPiican� ��a �-i �Sc ( I Subdivision: � Kc � �� Section: Lo� mc(z' l.ccS /Yli l f 2d �2) C�� Cz'roVc' Klcy 2d _ d3e�� U �-t ��r� l��J Gi.� ��1tC P; �K.et FcncG /�Ol-45L �S�j� Cc� �nCr 7Cy�e of Water Suv�lv: Rec�.uireffients: 'Y TI1diVYt�i1�i�. Site. Approved bp 1Ct '�� 3�+ Gmuting A mved b � H' q`'f�'�S We]1 Log ��`1 4 "r� �b� Well T� .�I Veilt Hose B� Concrete Slab Well Driller. COiritllLlillt� P11�JI1C. � CI� �c.�( . � . • � �a �c,s� � � ,� s ro� � Well Approved By: Date• '�°5ee Attached Site Sketch'� Wells must be 10 feet from property 1'mes. Wells must be 100 feet from septic systems. � Wells must be ax least 25 feet from anp biulding foundation. • .. :. � S I<ccn Wc.(t SO'niu.s Fra�'old w�tr� _ /Zd, PCE�, rev. 09/07/Ol ��,5�� .�� ooc�ao� 2309 . .. ' _- �_ .;.� `�1' � � 11 11 ("""....'1!"""'..t'1 .11�K1d1UW' ' NfV I T I%'� �'� { � � V 11 1 � ♦ �„' '�.n��vii �r•,.ca�i,� :�� c�-rnt�-tn�l �L��.en.�tC.�a LJCslISI� LJUU�IJlyl9J � I � �O� " ` ',11�. G out Log n Owner: �a,��_'�' �� W 1�,��L� Tax Map1V35 Parcel #�� Location: __ .___ � Subdivision: _._ _ Lot # Well Construction Distance From ne:�res�. I' operry Line (Minimum 10 feet) � Distance from e:;:�c ��. �tem (Minim 60 feet) Total Depch: �� i� Yield: GPM Static WaterLevel: 3� ft Water Bearin� Zon�s: L�:�th ft f[ ft ft Casing: i • - .. . Depth: From 0 _ __ . � �� _ � `t. Diameter: �_ in Type: Galvan�zea �t�� _ � ��'eiah�: _____ �'',ickness: �� Height above Ground: in Drive Shoe: :'�� No Any problems encountered while setting casing? ,.._Yes _ No If "y�es" give reas�,n: - -- Grout: �",;: _ _ _ _ _ �and/Cem�nt ✓ Concrete Gravel/Cement .ann�.�l:. ��;�ce \Vidth inches Water in Annular Space Yes No �-1et!•��ci ;;i� Grour. Pumped Pressure Poured ✓ Depth � to �� Ft. !�Iaterials Used: `;o. :;,..� ,:�..�riland cement Weight of 1 Bag Pounds (f n: :;��..:: � anc!. ��ravel, cuttings) — Ratio to ID �,i;�;:�; _✓Yes _ No 4 x 4 slab I� Yes._No Drilling Log Location Drawing � — ---�_ . _ i � _..._.. -- - ; __ _ . I herebvi certi�v �'� . '��'•° inforni�ition is correct and that this well was constructed in accordance with regulations set forih bv the f� ��- �� uni�� Flealth De�artment. � ID#�3�� Date `1'"�'1"�3 SiQnature ��f C�� .� �• ..,_... " , PCHD rev 09/30/Q? \��r�� J@7 � �� \'y l,� i/ /�`Q /� `�` T �^ Y V �� IE�.�� -��.S.IL I��.1L.�I(s � . , � A��IicarrC � x ��3:�,p � � �,r�c�l ��LI'tJ:1:4i� `vr �`�'.��11;1 � / . ,�il:a=4�� 2 ^�! O I�1r �0�[ r . �1"��C� � ��` � �t . � � � S stem T e In Acr.ordanc� �th `i'abi�e Va): ��- Y YP ( . THIS SVST�iVi i-10�S • BEEI� li�lST.ae►LL��9 !N Ct3ilfiP�.9,�+P10E. � l!V('iFl APPLtCd�BLE N�ia�'1-� C�►ROLiNA GENEFd�L STA7'U�S, �RlJLES Fd�EC SE'�iAGE"fRF�Ti�iE�'T A�ID i�iSP�S�.., . AMD AL9�. CONDIT1�6a1S ..OF THE 18N1�FZ��99�E3VT PE��A�? A�II). �C�NS�UC?$Otd � �AUTHO TiC? _ . � � � ' . . -- .. ..� � . . - �nl'e/ • : _ � - � � • ' '�� l �.'`' p �j. . • • • .. . � -Auihorized State Agent � . • . � . � . � .- • • � Date . ' lnsialled � �. . . . . . � aate: .. `� � �� . • - - �j; t �n _.__ _....:._._.. .---- �o. __ ..... . ..._. � ��` �; ��S (� L� ►' rc�-;�: ��. o7�2n��z � c,.�� '�� i��`�� }��1��` �� - d� � Ta: NIaQ � '�� Farc�! � 73� � Syste�n Type (T�ie 1��) � t�wn�rlAp�dicarrt Sisbdivision � }�dd�..sslLocati�n � S��ase [�t # St�at� ID/date � G� Capaciiy. �@�v'n . i Tee and Flt�r Baflie Sealar�tt Risef (i� applicable) T�nct� Wid#h irench. Depth _ �'ren�h Grade � Tr�na� Spacing Roc3c Depth and Quadi ft. in. ft. � Tank Ou#let:�Se�! . � . DamslStepdowns �et�. -� Pem�anerrt i�iarker . . . .. Pressure l.a�erals . —, � � �a� i'�aak . Hole -Spacing . ''' • . , � � � tate at� � - � o e izs � - �-, . . . Gapacity. ' � � � 9ai- - - - : . Pipe Steevs . ' . .... � . . � 1!�laierproof 1Se�laa� : ' � ` ' � Tum-u�s/P►vtectors - � .� � . _ . � Ris�r . � � . " . i�►�c�inas� S�c�: . . . . � 1nlater Tight . �rom Wells : " �ura�ap From Proper�y lines � � . . �bec� Vaiv�/Gaie Va�r� : � �� : Structures/Baseme� . � . - .: _ . �ti-s�p�on o e � . . � . � . � ... es ea�nage ays _ :. _ �. . � g�ioatslSwific�es = • � . � . .. . . . � . _ . - �Surf�ce�iNaters � �� Alarm• visabie and audible Pubiic Water Sup �ies EIectrical Campaner�ts Vertical Cuis f>2 #t Rate gpm � 1Nater lanes � Ap�roved Pum Model Vehicie TrafFic Bloc��lnder PumQ Ad'acesrt�Sysiems E'ump Rem�val Rope/C9�ain. EasementslRi ht � Ways . � �D�ib�on �s8:ean ' �er � S�iai Distribution —6r,.� Easeme�rts Recorrier� _ ' ressure an' ! - � perator orrtract � Low Pressinre Pipe � Tr�-Partai�e Agreement �Dar. Pi�e Material and. Grade � ttves � � . ' C�r�ee�' � . ,_ � . pr t� r�,r. 31'i3lC1 OI Ul1co� c r d� ,�.� m� T�,n K C1'�c�K For 5o�.ndrlcss �� n�-�i l I ncc,� Te c+�� tcr �JJ mpUe. : Io0" Fro�•-• Ti�,.�K d ex�a�atc l►nc• �►Str� t l 5-�� p d�'� n�- Fc c.d �o �w sYs�.�, w� 3" P u�, Main'�k�� 6`/Foo� Far�, � Fccd �cc� I��cs Fror► D-�� ZnSta II uP51o�� d' �-rse`on� !`Widc� Z•c�� 4,• P�pc on -Tt-e.nc.h bo-r�or. �� I,n tcs u�. Go�cr �/c(can ston�� {u�dP� pe. p�,�.�(cfs aro�,�.nd nCt� TrC/1C��S �� 3 o r 4« PvG -InS�, �� cnvcrs aUcr ends. t � I�s�� ,3- nc� N-�ihcs lo�-�►o' Lon�! U.Sin� 10,� �gc. DiamcEc� {�rPc �`�c To S�o�i�y ,�itc,cond i{�ons, 4 �1� �-xc..��Gtt �. �. l S � Q�`St �tc.Pdcw n �� ncca -tr cn C[�cS � 2iLt-�i l�' cJ cod C� tCC P� 5C i�� 6� o�, � a � ,,� � 1.��i� -„��.i��" ;�! . - .,....,. � � , Lo7 8 g.07 Acres �� --� �� . � : ,r, ' \\ .��' • ;� �Oi riCC85S GaSE1T�9n� S2a P.C. �F-1=4G � � .�� 4g �. �z,' �.!� � \� �'� � `` � �� '� � �� f ��.�� '� � �.. �— ;W � , = � c��CT��°� �. �_ � J.L�R7i:�iL7C�nan-D[n_�1C7,.��.tn.lL ll J.��.at,��t�J�a �� N N �k� SI'I']E SI�TC�I � � �'' , ; i Name �� I l�a� l,��i tF� c ld� W�nd� H�ss� � l Tax Map # rl� Pa�cel #�`3 �' Su � isi n Secrion/Lot# , �� ' 3-13-03 Authorized Sta.te Agent Date '; ; .,.'s System cofn�onents rejiresent a�i�iroximate contours anly. The contractor must flag the system prior to �, �' � , i(':"� .., vc� K,�+. = .-.., ,,, , F.l i�� ii_