A40 205mount
Rece�pt
�
E-�
O
�
C v
paid �J�' �
.l� � � 7-]�_
I �• i
. ,��
5����.�,, j o � q��
Date
. nnr rre�rrnrr rf1R CF.RVi('FS
�
W
U
�
a
z
; � , .� ...,.. .. _._ _
' Bacteria Chemical Petroleum _Pesticide
Permit requested by: .
ner/prospective owner/age�
,dress: � 3 8' CT� � s -f:c�
i � ti_ c..p �., L� lc.e .�t• �.
7. Dimensions or Proposed Structure:
.e w.CA-f�s Width: C
�. ...�. Denth: r7 D
Lead
�� 3 8. What type (if any, additions, expansions, or
replacement is anticipated to the structure or facility _
^ ^ n that this sewage disposal system is intended to serve?
omePhone#: �3�' 3�`������
usiness Phone #: �I l 9.� .� �� � �3 �
ame.and addre�s of.c�rrent owner:
— 1 `73
: Lot size:
Tax Map#: Fi'�-�'�a ��
Parcel#: a U � � � �
Township:�� f�t • �� �� r'
Directions to property: State Road #& Road
ames
L/�1�N?/}-f( U
��1�-� o ti—
- fJ r � u -�--_
9. Water supply type:
privat�. public ❑ community ❑ spring ❑
Are any wells on adjoining property?Yes ❑ No j�.
If so, identify location:
��ype of structureJfacility: Proposed: C7Existing: Q
Type of dwelling:
House: ❑ Mobile Home:� Business: ❑
Type of business:
Number of Employees:
Number of bedrooms: �— �
IGarbage Disposal? Yes ❑ No I�
Basement? Yes ❑ No�7 If so, # of basement fixtures:
6. Number of occupants or people to be secved:
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES. .
I hereby make application to the PerSOn County TdeSlth lDepartmen� 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 ttiat 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 and all fees paid forfeited.
E�;�� �� �'
Signec� Ow r or Authorized Agent
Permit Issued ❑ Signature Date �
Permit Denied ❑ . - '
Plat Observed ❑ . -. : •
, ._ .
__. _ ._ _
- --,. ._ : ... __ _ _ _
. , __,. ,. ..
... . _ _. �__,
_ - ,.
_ .__ ;
___ .� _
- . � � ; �. �
c��ta�' � r 3 F.... �1SCfORSSTiEkyALllA�7S1N6��%.K.. k `:.r.s: z�K<. ��>. z�'-hZ � ARFJ1�..>:.= � gs. :..9, s","r.�.�.C'4.7.'3;` ,.i.�..���::'fc'�1'.YYk:
. ..<... � .:. . �..,. . ^+,......... �S i.c..e...
!. SLOPE (%1 S S S ._ S
PS PS PS PS
U U U ' U
2. SOII.7FJCilJREU2-361N.) 5 g.- -_. ._ S.. S
(SANDY. LOAMY. C1J+YEY. NOTE 2:1 CLA� PS PS PS � PS :
' .... � U U . . V. ... _..,r U- . .._ ._ ., .:
3. SOILSIRUC7VREp2•361N.) • S S S S -
(W1YEY SO1LSi PS PS PS PS
U U U ' U ,
3. SOILDEP7}i(WJ S S 5 S
' PS PS P5. PS
V U U U
S. RESTRICTIVEHORttONS (iNJ S � . S . . _.... .. 5. ,'. :. . . � . . '. ,. . S -. _ ; .:..
(IMPERVIOUS STRATA, ROCK) PS PS . PS PS
- _. .
. -.
. - u. . .. ._ _ v v..• •_ . .: ..r. U
- _. - ... .
6. SOILDRAINAGFIGROVNDWATER S S �.- _ S - S
(FJC'CQtNAI. R WTERNAL) PS PS PS . PS
� p,, U U
7r SOII.YERMFJIBII�TY S S S S
(PERCOLAATION RA'i�l PS .. PS PS PS
. .. . - ._ p p U U
E. AVAIL/1BLESPACE _ S .• S . S . : S
PS PS PS PS
- U . : V, • V : , V :
9. SiIE CU1SSiFIG�'I70N(SEE BELO� • . - . , . ' .
SOiL SERIES : • : . . . ' - . , .
• S-SUITAIILE `PS-PROVLSIONALLYSUiI'AIILE U-LJNSll1TABLE
RECOMMENDATIONS/COMMENTS:
SI'TE CLASSIFICATION DIAGRAM (Include: Soil �areas, property lines, roads, streams, gullies, wet areas, fill
areas, wells, water bodies, slope patterns, etc.� C:V�M(PRO�DOCS�APPSEC.Srt FlNANCEPC .
�
a
w
�
a
B 2569
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # `7 � Parcel # � � �
Zoning � Township -i— i
Owner/Contractor
Location/Address
Subdivision Name � � ,(�i i- (�.i
Lot#
Date
1`' LGLf ���t%F-i DY1 QUc
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area 1• 3�i�`i' �
SFD Mobile Home �
Business # of Bedrooms -3
Permits may be voided if site is
Well and Septic yout by
Comments: n0.�
Date
:
or
S.R.#
Size of Tank � 6��C�-(
Size of Pump Tank � N
Nitrification Line ����X3 '
Max Depth Trenches � y � `
use
i by
�
ell Permit Paid C7� WELL SYSTEM SPECIFICATIONS
dividual Semi-Public Required Slab ✓
�blic Replacement Air Vent ✓
te Approved ✓ Required � 11 Log �. G� I Z�8
ell Head Approved✓ Well Tag
�outing Approved C_�(' , j I� q ��1'� __
Date /��y-� Installed by /-��E i�%�� �������1 Approved by��U��_
C�a%,� Ys i �
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permit. The environmental
health 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 will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam Ol/95 rev.l.l
- :� � �/ � .
� � ��
� �- 2 5 ' I��
V q • `y .
��qN � � .. �, � .
., E � t�, , 1.30 AC. ; 0�' 5-A \
� � ;,� ' � n`b 2 � _
.
_-- _- - "�so 9.45,� �^ � DpRRqN ?�'i� � .60 AC. ��� � �
; � oo • z � �E C pUR.T �� � �;
.�
R,�, � S75a53, �__, �� o �
� �, ,� _ 2eo, 06 � "F �
,
p O h � NF 50� R
, V . ' ,�S�
' �o`� � � -Jro, R�w� 1..� � W '
� '� �. �
AC. , N ,
= 26 % ''°�5• �
' � / 3��• 33 �•� °�' m :'
� � , 3��s� �1� AC. . �� �
. �,
� �1 N
0 -� � .
. "' 3 ; ? � � � ; �
. � � ,, o- _ 26_A �,
, . - 's •�, n � o �� �,•
,
' 36� /' � +7TA� 436 X�� y �.94 ACa �
r' ; .;. •60• : w 44'
r �y :-: . s �S I s
� ' ?s9 s22 � ' .
, us . � . o. .
� �
t ;:��v �F � o
' � °�ry -- . �00 0 ��t��.,,,/j X ` `�i N66•2p��:., N66. 6399• �Ct( Q � . _
ti O. �
• !9p��� �C� ?p . V��.� . o
: ' bry^o, � 1 . v�
,z,'� ►. ��� r g a .� v ,�i , � � , � �; :
'" � Jb �C• �, . /
O �
�' ` � �
�r _ � C' � .` �O .'
;' � '-� � � • ,' a
t � �j( � �.
� �� 1 � f:, i -�� �J, . • ,h
f x' �'i 0,. . . b �
. �, � ry 6V � � V +� o^ �o
: \ '" ,. t ah' y � ti� �A ���.
�, - �.- .�.:- . �:: 1 T'- �` t � i � � � � . . . !_
o ', ` �+ T?6 ? ,dOOe ` `A a s; ,,1� , i 560��,�,0� / v /'.
� ����Y�S,s�o�, ;� n 9. ��<qN �N °` � ,�
D; �,� . N o %�
.. �
f � ' I :. . S'eo C .,, '
� ;`; ' �-� Q�t
� �, � .
� `� � �:75 AC. B 71 S'�, S60'43'35"W
� _ .\ �� 33.94' /`
� • :- '{ '0 A� . 60' R/W ' ���
� (,� � W Y � � � � �� • ' _. ' 1
; ; �.41, 4 „ • ., li' ,
-';` 599 �3 ,; - , , ._ ^'S�. � / �V
` � N85°OB'43-4! •.�.: 19..8 . � '' p90 f
y -:200: 00.':. . S60'43'35"W _ ?'�6 9 S+
�"
� ,' . _ 33.94' �� l. �✓
f:
�`
� ` � �.
� � �
� , �'o�
� .
. EA , I , 3y��
�� � .�
� - .y�
,
. • �q �aOp i � � ` � f�j'� l
I v �i
_ � �
v
��\
v
; �, �J�p
:
�
4 �Q
NF p
lf
North Carolina - Department o( Environment ana Natural Resources - Division of water Ouality - Grounciwater Section
P,O. 8ox 29578 - Raleigh.N.C. 27626-0578-Phone (9� 9) 733-3221 '
- WELL CONSTRUCTION RECQab
DRILLING CONTRACTOR: �' J'�'`'
DRILL�R REGISTRATION �i: 7 � �
STATE WELL CONS7RUCTION PERMIT#:
1. WEI.L USE �cnecx appuca�ie eox): Residential � Municipa� Q Indt,strial ❑
Recovery [] Heat Pump Water Injection ❑ Other � lf Other, List Use:
Agricultural ❑ Monitoring d
2. WELL LOCATIo (S ow sketch of the location belo�v)
Nearost Town_ �j� �� r� - -- Co�nty: �S °�^
�s7.s Pl.�,�-f,�, �� ��� �. 7
�Road, Co munlcy, gr Subd�v�s� n and Lol No.) D�PTH
3. OWNER � (i' ���'� From To
ADDR�SS ��°d�' D � US 70 _
r r' I�� 6�2� ��{Streetor_go�alloJ � �� _
.t ���
DRILLIfVG LOG
�ormatlon Qescription
City or 7own O Siate 2ip Code O' �� �,
4. DATE DFi1LL�D��
5. TOTAL DEPTFi ,���„ � — ,S• ,��� � nG.w�.
6. CUTTINGS COLLEC'fED YES Q NO[� -
7. DOES WELL REPLACE EXISTING WELL? YES ❑ N��
8. S7ATIC WAT�R LEV�L geiow Top ot Gasing; 3� FT.
(Use ":' if Above 7op of C2singj
9. TOP OF CASING IS � FT. Above Land SuriaceW
• Casing Terminaced ayor beiotiv �and surtace is mega� unless o variance �9 iss�ed
in aCCorddnCe witri 15A NCAC 2C .0118
t0. YI�LD (gpm): � MEiFtOD OF 7EST �_ ��� ��
� �. WATER ZONES {depth}:_,. � � " ��-S
12. CHLORINATION: Type .. !c1'�µ Amount � If additional space is needed use back of lorm
13. CASING:
Wall Thic�cness �-OCATIOfV SKETCH
Depth D�ar�e�a� or Welght�Ft, M,,at� f.ial (Show direction and distance from at least two State
From �— To .�-L Ft. ��-^ `�-� Roads, or other map reference poinls)
From To Ft.— —
From To Ft.
y4. GROUT:
a Depth Q M�ierial Method
From To �_ Ft. ;� � ��� �—
From 70
15. SCREEN:
Depth
From To _
From To _
From To _
16. SAND/GRAVEL PACK:
bepth
From To —
From To„�
1�. REMARKS:
Ft.
Diameter Slot Size Material
F1 in. in.
�t. in_ itl, _..
Ft_ in_ in.
Size Material
Ft.
Ft.
j�%
�ay �j a rD
�
I DO HEREBY CERTIFY ThiAT THIS WELL WAS CONS7i2UC7ED IN ACCORDANCE WITN 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND TFiAi A COPY OF 1`HIS RECORD HAS 8EE PROVIDED TO THE WELL OWNER.
r .�. F�U ,e �r • 1�'1f 1 1/� ]F'� _ 1 l � ! t � �
�
F;:�,��;Y$r�:��r :�°��. -���4��'�
�u�i� o. , °
!bS 81 i{:tja�r*+�i•.:: �. ..1�•.'b !(�E�f�
yy.Y �f�.f������ I�i����'`;di17 J
��, ',-'c',.:'� �:'
SIGNATURE OF CONTRACTOR OA AGENT OA7E
Submii original l0 Diviaion ot Water Qupli�y a�d Copy �0 Well OWnei.
dW-i R�V, i/98
Z0'd T46T 8ZS 6T6 �NI�NI"1'1I21Q"l'13M3'SH Wd LS:60 Q3M 86—T i—AON