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WELi �7u ���vAGE SITE, LOCATIQN IMPROVEMENT PERNIIT
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 # �- � Q Parcel # � � �'
Zoning Township r� A r i� i,,•� �
Owner/Contractor��.�, � 1 � � ;,/o� ,..>>� �� Date � - � t, - � �
Location/Address ,y,,.,, y i,3-7 c' T/�' o� �.4 r�v�s T.4 �Oc`�2�/ i?A _
�• ! .y�� � �T � S.R.# ����
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
Repair Lot Area Size of Tank >ocao 4A �
SFD Mobile Home Size of Pump Tank ,a/q
�uFiness # of Bedrooms�_ Nitrification Line ��' X,3 �
Max Depth Trenches .�o'� - z y��
Permits may be voided if site
Well and Septic Layou+.. by�
Comments: f.:�zcv;..i c��_
altered or intended use
Date �-� p- 9� Installed by 1Z. �/��ZiV�V"7� Approved by.
ell Permit Paid �/ WELI; SYSTEM SPECIFICATIONS
3ividual t� Semi-Public Required Slab
�blic Replacement Air Vent �/ � �v� 4•,%
:e Approved Required Well I�og
ell Head Approved , p Well Tag t/
�outing Approved
Comments:
�/Gi{
DateJp / j-� 9� Installed by �� Approved by Gl/�.:iJ� ,,,� .�.t��.L
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 ale,o not
responsible for concealed conditions on the property or for statements in this
report that may have resulted fror,n false or misleading statements provided to
him in the application. Neither Person County nor the environrnental 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 O1/95 rev.l.l
Apalicatton Date: g�"� � 6� . Tax Ma #: 4Q
Amount Paid: � n .
Recei t: �'d- t Z Parcal #: a G
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1La-a_Psa-m+sa-'•^� mna��.Il �-�om71�7�s
APPLICATION FOR SERVICES
IF THE INFORMATION IN '�HE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT. FALSIFIED,
CHANGED OR THE SITE'IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID. •
1) Permit requested by: (Own rlagent/prospective owner): YY+'' � P�`�2�^�N
Home Phone: �� � Address: 2� 3 p,q,,��,� s�',;��,uc� I'
Business Phane: �,���,�'1 Gj�' �o,�� ,�I� `tS� �T
2) Name ar�d address of current owner. '/L/-! c�
S T��n
�v 1L Bo j?�+ ,t/G Z:Z7 S-7
3) Properly Description. Lot size: �'��S Tpwnship: �fL�Y�'�Subdivision: `� Lot #=
Directions to the properf�/ (Including road names and numbers): �/.�.�t,a-,n ST 7� !S? /�fu�a!!�
�
4) proposed Use an Stwcture Desc�iption; answer each of tFis following questions:
a) Proposed Existing _, Type of Structure: ►-�o��.�.� �rc- Width: �iq' Depth: ��
b) Number of Bedrooms: _,� Number of occupants or people to be served: �_
c) Basement: Yes,`,�/No _ Will there be piumbing in the basement? l�_
d) 6arbage Disposal: Yes .� No' ✓
5) Water Suppiy Type: Private ✓new,_ or existing�`�Pub�l' � Community_, Spring _
Are any welis on adjaining property? Yes_ No ✓If yes, please indicate approximate location on the.
'site plan,
6) Does your property c.�ontain �reviously identifled jurisdtctional wetlands? Yes_ No �
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PIROPERTY OR SI'I'� pLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. -,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STA�CED OR FLAGGED.
➢ THE SITE MIJSi BE RE�►DILY ACC�$SIBI.� FOR AN EVALUATION BY THE HEALTH �EPARTMENT
STAFF. _
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposai
system for the above-desc�ibed property, I agree that the cantents of this application are true and represent the maximum
facilities to be placed an tt�e proPe�Y. I unde�tand if the site is altered or the intended use changes, the permit shall
become i�lid. ni ���� ��/%:. ` ,
Kep�esentative
ag v
Date
PCHD, rev. O6l27/02
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Applicant:
>
Ta�x N1���E� ► Parcel # � =
S�uhclivi�s�ion
Fh�a�se Sect�ioii Lot =�
a��-
Improvement Permit
Permit Valid for � Five Years No Ezpiration
TypeofFacility: � �1��_ ��1.:.� New Addition�C WaterSupply�
# of Occupants r,,,o,k # of B ooms `3 Projected Daily Flow 3� v g.p.d.
Proposed. Wastewater System: •
Prnposed Repair:
Permit Conditions:
�
Owner or Legal Represe
Authorized State Agent:
SC7 -G��-
Type:
Type: �..
n�
Date: �" ��I a
Date: � -�� �c�'
The issuance of this peimit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicandproperly owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are 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 c�mpliance with the provisions of the North Carolina `Laws and
Rules for Sewa�e Treatment and Disposal S ems' (15A NCAC 18A .1900). Neither Person County nor the Environmentat Health
Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that. the water supply w�71 remain
potable.
Authorization to Construc astewater System (Required for Building Permit)
* See site plan and additional attachments (_�.
Proposed Wastewater Syst � Type,� Wastewater Flow 3coc� g.p.d.
New � Repair xpansion � Soil LTAR: , 2�5 g.p.d./ ft 2
Type of Facility: Basement Yes � No
�.�,�;� V�astewater System Requirements
Size: Septic Tank: /C_Q71�� ga����' Pump Tank: �--- gal Grease Trap: � ga1
: Tota1 Area: sq ft Total Length i 50 ft
Trench Width � ft Minimum Soil Cover: �_ in
Distribution: � Distribution Box � Serial Distribution
Authorized State Agent: ` �da�
Permit Expirati�n Date:
Mazimum Trench Depth a �+ in
Minimum Trench Separation: �_ ft
Pressure Manifold
Date: �-g-z��/
The type of system permitted is � Conventional Innovative Alternative. I accept the specifications of
the permit.� �
Owner/Legal Representative: � ; Date: �6 �
PCHD7/30/2002
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Tax Map # ��o P��� # a��/
Fxi4ting Sewage Syatem Report For. ,�,_ Mobile Home Replacement
- Addition Type•
Requester: 1`�'In•� � � � �v�svr�. - _ _ _ Home Phone# Sgg - o � 8 �/
a'7 � i�: na..� Ia.v¢� � Business # aa� -��� s
i`�,.�-�.� � �c a�s��t _ �
L.ocadon: �l S� 15'� ��lw�.lx i'1� .11� �-iw��� � t K) C'n �a.c/ns�r (a�uen, J�
--^� drn�-�w�, � L- . �3 /�1�s lG.c)em 12.� .
Original Permit Located: � Water Supplp: \t�l�a-1-c-
Septic Sqstem Designed For. �Iteaidential Bnsiness Other
# Bedrooms�_ # Employees Othei
System Type: %.}-+� Taak Size: 1 cx�o Nitrification Line. � k 3�
Date Installed: i— f�l -ci Cs� Cerdfled Operator Requited: i(1C. �
On-site wastewater dispoeal sqstem shows. no visual signa of malfunction o� �-9 — C� t� .
Permission is granted to•4��cac;,2.. C..�l�l LJ�'� ��f .
Comments• �Q�•1'��-c��n C�Q,� c�-2s1�O��A.
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Environmental. Health Specialist Date: �
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SIT�. S�T�
Name ��t�'I 1, n NuIQrY+�� Tag Map # A`�o Patcel #���
Subdivision �'73�.��es i �o•., 2L � Section/Lot# �
� � �r-vy
�luthorized te Agent : :� Date . ; . . �
Syrtem components s�e�br�ssent a�pmximate�contours anly. The contractor must, flag the system�irior to .
beginning the rnstaAaiion to insurE thatpmpergmde is muin�azned �
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Scale: 1Uo� � �
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Applicar� �-�1n'Il.
Location: t5`� s -�
T��x ia�l��;� � P�,rcEl = _ .
S�uf�ci'i��,i:5�ion
Ph:���e Sec�tio�a`Lot +=
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. ��peration: Permit . �
. �. � �
System Type (In Accordance With Table Va): . CL Q �
THIS .SYSTEM HAS BE�fV IN�TALLED � IN COMPL.lANCE WITH APPLICABLE NORTH
CAROLlNA GENERAL. STATUTES, RULES .FOR� .SEWAGE �:TREATMENT ANQ �DISPOSAL,
- AND- ALL CONDITIONS OF T�iE tMPROVEMENT ' PERMIT .AND CQNSTRUCTION
AUTH�I�IZaT70N... � . . ��
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Authorized tate�A nfi � � � . � � � : • : �Date � - � � �
Instalied By. �a.� . . . .. Date: � �- y�- �5 - � ' ' , -
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PCHD, rev. 07/29/OZ
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^ ?'EitSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
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Date: ? ! ��'
Owner: Pti; /,�:� �-fG/eM an � SR# �� �2 �
Location/Directions: �� Y � � � � ?/•Q �H ,� �.,,� �s �'����h �� . .
,
��-/ n-,; �-e o v� � e � r � • .
Subdivision �Nvne: Lot #
Drilling Contractor: /(�,-�ti /3c.-rr e TTL'
� WELL CONSTRUC'I'ION
Dis[ance from Nearest Property Line Distance from Source of
Pollution
Total.Dep.th: /o� Ft. Yield: 5� GPM Static Water Level 2S Ft.
Water Bearing Zones: Depth ��-3 ,� t. �o-���F� Ft� Ft.
Casing: Depth: From O to 3� Ft. Diameter: 6% Inches
TYPE: Steel - Galvanized Steel �
If Steel, does owner approve: Y�s No
� Weight: � Thickness: ./ Height�Above Ground: �' `� Inches
Drive Shoe: Yes X No . � �
Were Problems Encountered in Setting the Casing? Yes No -'
If "yes" give reason:
Grout: Type: Neat Sand/Cement ?C� Concrete
Aruiular Space Width Inches
Water in Aruiular Space: Yes No
_ .. Method: Pumped . _ �Pr�ssure � Poured_, C�-_- � - - _
Depth: From O to � Ft.
MateriaLs Used: No. Bags Portland Cement Weight of .1 bag_lbs.
If mixtuje (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes � No � �
� 4 x 4 slab Yes � No
� DRILLING LOG �
De th �
From To Formation Descri�tion
e
2 5 7.7 �� c G
7 � 1 W � r.=.
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON CO'Ji�'I'Y HEALTH DEPARTMENT.
Signature of Contractor Date