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Hcros Pha� 9 i - � 8G. — y � �, Addrssx _ 31 � •�I.c4x •a.�c� .Qre
B�i1liQii rIMiO: 3'wq.t. 04�I�,�/i /= /VG � ��'��
xj N�ne and add�s af �urtactt owner. t�s•Q �.acv< ��i
� g .vo%c.ycrrv ,4vL
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3) Prop�Ry O�scription: l.ot ��'� Tow� .IAP- 2�� �2
Direalor�e to t�e praps:ty prx.�udin4 road namea and numbea}: /-�wy /S�
/�/.Cf.3 OCi77^! �� /Z'•OXL9o/'�A vN G3 `LST ��Ati a� /�'tJAs�
4} Prapc��d Ua� and 8tr�,tn t3qtrtpt3on: anawer tad� of the fo�cwirtq qtt�orsa:
�) �d 1�' F.x�r�0 �
b) Stlydc 8u�i Q Moduiu G Singte WEde,RZ Da,Dle �Mde,td
c) Number oi 8ad�qoms: 3 � Num�ec o! o�
e) 8asers�t Yes q No�t yea, # af ba�m�t tbm urox
� Gs�e Ofspoaak Ya 4 t�iolrl'
� Dtmansbcts ot Frapos�d Sbu�ro: Wid!!ti:'�'S peptlL 3'S
or peo�1� io be served: y
� W�br 3u�P�Y j`�fP+s PitvsLs,�f(ttew,�iac ads�r�9 �1. Pes�c 4 Cocmx�Y a. 9pc�o Q
Are �rty weila o� a�oMi�O DroP��R Y�� No 01! yes, bc�Or1 �'T 30- A
�} Plassa IndlcaL� Drslnd Systwt� TYP�= i�� can b� ratsbd !n ard�t' oi yous ¢ethc�)
� Coitv�ctttottal l�odill�Cf Co�tv4tttiort�l ,__, Atl�w Z�rufov�t!!v�
Olt�s� (sp�!!�:
CIEARLY. 3'T'A� ALI. CCRNEAS AND L1NE8 OE� THE PROPEEiTY.
8T�JtE 7HE CQRNEi�S OF �LL. PRQPOSED STRtJCTUR��.
Pt.EA3E ATiACH SURYEY PLI1T OR 3iTE PU1N TQ Tii�B APALICJITICN
� RerebY mika aPQ8ra1lO�t ta tt1� Pecso� Covtlty Hsaith Q�artrn��t 1or i s� w�tttsdoc� 4or ttw on-ata sawa0� d40osai sYs�m t�
the ebove-d�d ProP�Y. I astee 1t�at � Cast+ec�ts at tl�ia ap�p�at�on ar� tcu� and c�,u�nt tlx ti�dmum taa3tles to �,
p�csd on tho pcoQecty. 1 ttr�deratand if tt� s�e ta aitarad or th� lntanded us� c3t�, tltia pem'� altaM bacact�s tnv�lld-1 und�ts�r�
tt�i �s appik�nt, 1 am �eap�ie for idcntliying and snui�in4 P�'�tY �0. �'s and ne�idrq 1h� siba a� [oc th
PeracnrtN of tlze Pason Cautty Fta�►tri Depa�irtt�rtt to conduci tl�eir waM�stfortis. l�asattid tt�t 1 am t�spo� ���4 �
H�aittl Depat�rnent if my p�sty corst�ha st'ty we1lq�rsd� aa dtsiqnbed tR► tt� AcntY Corps ai
_ - r'6 03' /
OM�f10f Or L�I iiOpf�Eei1�(Ve � �
Tax Map #:
Locarion:
PERSOiV CeJUNTY E9VVIRONMENTAL HEALTH
Parcel # �� TownsMip PIN
� "� Subrlivisia, � 1 —��s PhaselSecUon Loffi�_
Imarovemeni Permit
New �Addition Type of Structune ���- ��'e� . Water Supply �'
# of Occuparrts6 �X of Bedrooms 3 Other
Projected Daily Flow: 3� g. Permit alid For. Five Years ❑ No Expiration
Proposed Wastewaier System: �Ll `n'vr �
Proposed Repair.�vlvtdv � 1re-- '
Permit Conditions��� �i � r� Sl�.'e'�C �-. � '
Owner or Legal
Authorized S#atE
System Type �l=�-
Date:%�'�%d/
Dafe: V��$ v �
The issuance of this permit by the Heaith DepartmeM in no way guarantees tf�e issuance of other pertnits. The permit holder is
responsible for checking with appropriate gove�ning bodies in meeting their requirements. This �ite .is subject to revocation if
the sibe plan, plat, or the intended use changes. . The Improveme�t Permit shall not be af�'ected by a change in ownershlp
of the site. This permit is subject to compliance with the provisions of the Laws and Rules for Sewage 'i'r+eatmerrt and
Disposal Systams of the North Carolina Adminlstrative Code. �
Wastewater System Description:
�'l - WastewaterFlow: ��v a.p.d. 'fype:c�
FaalityDescription: � g� � l�`P5• New�
Basement? a Yes �No Basement FixWres? 4 Yes �No --
Wastewater Svstem Requiremer�ts
Tankage: Septic Tank size f a� v gal. Pump Tank sizs r gal. Grease Trap size
Repair ❑ Expansion ❑
gal.
Trenches: Total length 0 v R. 7rench Width 3 ft. Total Area ��� sq. R
Max. Trench Depth: Z l in. Aggregate Depth:�Z in. Soil Cover: 6 in. Trench Separation g ft. on center
Permit Expiration Date: � � �0 � � �
Authorized State Agent � l%el Date: �Q �� v�
*See attached site plan and addendum pages for additional perntit canditions.
The type of system permitbed O does O� does not differ from the type specified on the appiicaticn. 1 accept the
spec�cations of this permit ,
OwnerlLegal Represerrtative Signature• ' Date:� ��{-��
O�eration ermit
System Type (in accordance with Table Va)
This sysbem has been installed in compliance with applk�ble North Carolina (3enerai Stahi6es, taws and Rules fo� Sewage Treatment
and Disposal, and all conditions of the Improvement Permit and Construcdon Autlwrization. Issuance of this permit implies no
guaraMes that the sysbem installed will funcffon properly for arry given period of time.
Authorized State Agent
Date
PCHD, rev. 03/07I01
� �P9�,� �4�j �te�itla i3ep�rt�ers# . �
. ' � • � ��nmerotad Hesi�h �c�ors T���� � . �
. . . P�caa � �a �� _
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. �s e - s�bdtvisior�SectfanlLa�
' � c��r'�c� � �D = (�6- -�' ( . � �
.-Ault�orized 5't�e AAen� � � � ' .
� � � � � °'rl�� T�r� � -�aq� �rsayn°°°a -
� p� m�w ilis � t� �+e pr�P�'R�
. S � ��r'� 57Si-�M � �� �'�{ ��3 �� .
v��� . .
��. ' r bac� ' �' s7s��, �`�
lad�,�,�" �`�S-�-P� d� ��� T►-a� . � �a � j�_,M ����5� .
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�v��tla-h�• � b1a� ��,��;o�s.
� sc�le: � �'� = 5t�° .
�'/
, . P�rson G�un�j Heal#h Department , ..
jl,,,, Env6ronrnental �eaiih, Seciion q
. Yax Map #: � �Zv Parc�l #: � a (
Zoning: Township: .
Subdivision: � � T'�� Sectionc Lot: �
� ,
APPlicant: � � �
Location: ,l� _�-_ ` "� � l
� Operation Perm it
System Type (In Accordance With Table Va):��
THIS SYSTEM HAS BEEN INSTALLED IN COMPUANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMI'T AiVD CONSTRUCTiON
AUTHORIZA N.
% �" %u—� �
A horized State Agent Date . �
'Taa: iYap #:
�' �— �'��
� �
s���
Parcei #:
�'�`� S�� e�
!%1 � PCHD, rev. 10/'12/a9
���c•
PE�S�R9 COUN�'Y ��IVIR�NME�IT,�L HE.�4L,�i�
PL�ASE ��� ��'�+��Ei3 PL.A� ��R VVE�L S1TE !�4'(011�"
Tax Nlap �
o P�� a�� .
Zoning . Townah(p
APPlfcant
��: ��l`e
'� �� � SS�
� �(
s�,�,��� �► �e-r �t�� f ��: � � —
Well Permit �
T�ae of Water Suaalv: Individuat Community Public
Reauiremenis-
Site Approved by �� I i-�5-� i
Grouting Apprqve� by � r+ ��-� S-o �
Weil Log V3 H� I(�� S-o
Weli Tag - � �`� o
Air Vent � <<-d- -o �
Hose Bib -�-�-v�
Concrete S ab ,�C «� �o(
Well Drilier• -r/� �� ��
Well Approved By: ��
;
Date: � � �� � �
**See Attached Site Sketch**
�Welis must be 10 feet from property lines. �
Welis must be 100 feet from septic systems.
Weiis must be �at least 25 feei from any building foundation.
Other conditions:
PCHD, rev. 11/29l99
Date: l/-I �/- o.� .
Owner: �' �
Location/Directions:
Subdivision Name:
Drilling Contractor:
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
ri,� rr ���.-r
SR#
LOL #
c
WELI, CONSTRUCTION �
Distance from Nearest Properry Line J v Distance from Source of
Pollution t G a
Total_Dep.th:� Fc. Yield: 2� GPM Static Water Level a?.S—' Ft.
Water Bearing Zones: Depth9� � lFt1l�: -� F� F� Ft.
Casing: Depth: From 6 to��Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel
If Steel, does owner approve: Y�s No
� Weight: Thickness:� '� Height�Above Ground: /�i Inches
Drive Shoe: Yes ✓ No .
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" gir•e reason:
Grout: Type: Neat Sand/Cement / Concrete
Aiulular Space Width - Inches
Water in Annular Space: Yes No
_ .. Method: Pumped � - Pr�ssure � Poured � - �
Depth: From O to �� Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag lbs.
If mixture (sand, gravel; cuttings) - Racio: to
�ID Plates: Yes � No � �
� 4 x 4 slab Yes � No
,
T HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C^vui1TY HEALTH DEPARTMENT.
� G� //-/�/'C� /
Sign ture of Conc ctor Da�c