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A40 274
b4/1y/1bd7 16:3@ ,� 3365977808 . . o . � o --�-o � 1�imoun_ t Qald; ,' (7Z3' l • � � ap 611 PERSON COUNTy ENIIIRO �p0 d �7��.0� � 1�.1 PAGE 01 `t � p'Bi�iL-���� �---,_�� .s i��7�.� �►1�7' ��.�.�s. �. �.�.r.�.� � �.7'�' �' �" �C�.�.3� - 1•� .�: ►�l - � "J �5 7 �' - - -- ._.. --.� . Water BupPly. Typa; prh,at�_ (ri�, ��, �s��, Pubib .�. Community� S rin .. '+Rt�a any wolla or ac�olninp properky? Yes No ._ tt yes. Ple�se Indicate appr ox�ma e Joc�ttori on tl�e '� P��1. • ,ti . , +' . s} Qoes your proPerq/ conlaln proviously id�ttliied 1W�dlct9onal watl�de? Y_, No�, P6�S� MOTE'i'Wg Fe t rw�nu�. ��, PLA7 OF TWH P�tOp�t7Y OI2 �ITE PL�pN MUSt B� 8U8M1TTED WRH TWIS APPL�CATiGN. D PROPF..itTY LINF.9i /1Np CORNERB AqUST BE C�q�„Y ���D. . % T!{��PROPO��D LOCA710N OF ALL 8TRUCTURLQ MU87' e� BTAfC��i O�R F'U4GG�. ' A THE SjTE MUBT BE READILY ACC�991Bl.� FflR q(�1 B1/qLUAT�pN 8Y THE HEJU.'I1�! p�3P,qR'i'i�1IEAiT STAFF: ' I hereby make aQpEication to the Pecson.Ccunty Hanith DepArtm�nt for e site evsWat(on far tha ar►�ti� sewaBe dtsposal svsiBm for the �hove-d�ribed property. 1 eDtae tha! the aot�t�ntm af thte appl(natlon ere tcuQ aqd repr�nt the maxlmum {i�e's to be pLacsd �o �he property. l undepgtand lf the sit� 1s alterod or the fntanded use chan�es, the pormit shal( • �me invaiid. / ) ' _ / � � �� D�te PCHD, t�v. 09127/02 �yU j3i '✓ �-: , ,.�� ��l .,�� _� 4,a� � � � � ,�� , w � ��) ,: U � C ���' s W (N ,`� C� c L . v��` �� � _ � �� V' _ n �`'. �, � �- J ��' � � � '.. �j , ���\ \Y ,,C� � r G�✓ C�i �<.' / , � \„`� �,)•L1 r� �1 r- � � � ��� \� '� ` �' �1�, ,\�� �. , �� �ti � ;� (^ 1 _, -J � r ! �� ��. ' �� s�, n� � �7N � rl � �� �� _ " �I �1���f�1 �1•� „13. �l.`Y �� ` ' —,".��-�1.�! �� w ���s�� -f-x-� <��.�.,�11. I�1'C��.11.�I1a A�plican� ��x Map � ' arc� . . Su,�.d!ivis�ia:n �� � � � _ P�h�s�e S�ction: � t � �•� �proveaanent �Ermit ' � ��snit'�a�id �or -✓ �ve ��� �+To �pi��tion . Type �of Fac�ity: � � �� �.s,� � d�.Y� 11 � -- - Ne�v ✓ Addition �ate� �u�Pfly ��_ � of Occupants �, # of Bedro 3� Pioje�ted Daily Flow �� g.p.d. Proposed Wastewater System: C`^.�-���nr�-�i �•rLr�O � Type:~0.. Propose3 Repair: Ar �,Pr� cl L�b r e c1 t� r�i � L= 7�l �.� 1� �r Chn rY,hor� � Type: —� c� -.. .....� , - ��.� C)wner br Legal Representative Signaizue: Authorized State�Ageut: �.� �: a � Date: The issuance of this pe�it by. the Health Deparunent in does not guarant� the issuanc$ uf other pem�ifs. It is t.�e respansibility of the � aPP��ProP�Y owner to in snre thai all Person Cowrty Pla�mmg and Zrnoing and Bw'3ding Inspe�tions reqwiremeais are meL This �iroveaaent �'srmit i� snl�jec# to re�ucation if the site plan, plat or the intended use ehaeiges. The Ymprove�eut Psrmit is not af�i'es:te� by a ci�nge in ownership flf the property. T7iis permit was issued in comgliaac�.with the provisions of ttte North Carolina `Zaws and i{ules far Sewa�e Tre�nent �d �isnosal Snsterns' (15A NC�iC 18A .1900). Neither Person �Connty nor th� Enairvnuaental Eeait� Spes.ialist'w�rraats Wat the septic tank system v��l cmntiaiue ta fnnction, satisfactorily ia ths fu#�e or'that the water snpply w�71 remain�potai�le. � — - � � � ' � Autfaori�a#imn t� Consirnct W�stewater SysEent il2e�are� fu� ��ding i'ea-�at) * SeE site plare and additional attachments� i�)- . Propose3 Waste�vatei� System: i.�r��l r�-ii e�nn 4 � TypeT� Wastewater Flow�g:p.d. New ✓ Repair Expaasion� . . Soi� I,TA13.: , o�7S g.p.d1$ 2� Type of Fac�ity: L�� �, nalP � � �� , � � ,.�e 1 � � v,o Basement _ Yes � No � � . �astewa#� Sysi��]�es�n�effie�t� iank Size: Se�ic'�anl� 1t�11 g� �p'�anP�: � gal �Grease'�rap: — gai �rai�dd: 'Tot.�l Aa�ea_ '�Qi s� � -�otal %,emgtL ;�{3� -' �ft � 11r�a�mnffi Tienc3r 13e�� � Cfl i� .� h,��.4 in �� Tre�ch Se�atation: � ft Tre�ci�'4'Vid#�t 3� ��'inimauffi Soi1 Cover. i�- : i�istr��ntnon: �C ��ibu�iion �og Speci�cations: Ant�ol'iZeai St�.te �igsnt: ` ct� ,�;� � � �' Pern7it Ex�iration Date• � o Serial �Distrii�tttaon Pxess�re Manifold Date: The type of system permitte3 is � C�nventional Acc�te3 Alternative. I ac��t the spe�ificatians of the permit � . t���rfY���al �.e�rese�iave: Date: � l�' d�"' � p� rev.1ll10/a5 ���� �� ���� �� �--`_ ��- � � ���� lE��ns�mm�.a�.��.Il. ]HC�.�:11�1� SITE PLAN Name ���: ,_ Tax Map #�� l7 Pazcel #�� S 'vision � - . Section/Lot# � 7 ' I����'i �O'1 Authorized State Agent Date Sysrem companeats represent appmadmaa conmrrrs only. The contracrarmustflag t6e sysrem prior m beg�aaing the iasrallatioa ta insure t6at pmpergrade is maintained � ��.�n�C1 Q\� Se�QC1� '�. ��-���� � '�r,S-�z\� �%� an C9r�D�s�r �`'aj t� � r� S-� 4.\ \ Sl 4 c�, Cn C��0.�.Y � „. , '� W� CIeO.r�r� 10� c1i��b ��1 as 1'� �1�e as �� ��e � �`�''� h��.�0. �,-� y_ � � . ' r, o� �,� 1 C�ver °v� �`� clXo�.�r,-�e1� � �r,y Q �.es-Ei �-,s �-c�c.�- Cr�,, �y.p, � 59'i- ��9� �e�S ACc� ' �15 I� ced�i or� � � �Z %10� or Ci�z+�•�r S '�,.,�C �-2 - � �= �°O � ;� � Y . � ��� � � � �� � '� � �i.����, �a---� � � . S � � y r � � , �1�✓ "�...% �� �'.S. `',:.� � I���..�-�a�z..-Y-TM-n ���.�s..1% ���II.�1i�. A�piicar� Lnc�r�n: � �I�ar� (���� 27y o n �QGij C� /o�►:a( �S',�d,�� I°r�i�`�� L�t� � /7 i3 � o� �-�`f�,� 3 . , � = - : � . r �i i� . . . . . .. . � � , S�st�m Type {ln Acr�rdaazc � 1JV'� Tai�l�a 1�a�: � a_ . . 'i'�3IS SYS'"�A � ��� If��7.P�1,.� � 1P� (X��diPL�hIC� 1f�6#i�i ��4..1�',���..E 1���?I-f ' �'�,Rt31:.I94d�, C�3�.A►I_ 5'T�;'TUT��, RL3L.�5 P�'J� S�l�+G� T�TD��I"C �L'S 1JlSP�AL; � • A1v1D ALL � C��4931Ti�[31�dS � C�� '� i°l�E i���'df.3id��i F�li' Ai�d� Ci�1�d�'i'RUGTI�]h[ • �1]'i#�CJ �`flt�6� , � , ���Z;►7vx-�-e �� • � ' ____r___ �/6/� 7 � . , ' ; P,uthc�a-i�ed St�r� Ag��ri . . . Da� . ! t7stall�i ey: ......._, T.-►..�. y. L e�,.: � S ' Date:�/�� S�D 7 ., n . ' � Co�otir�� �Sd.�{E-s �v�a�s`� . � � Lin� l.- �06' � ., � Nv �adSL Q!'���"�_ , ' . � • � � , Lr...� 2. ' �b 7 � , � , . � �T� ����.GG�to� � . ' ,�i� ' . (� �:n,L 3 = <<s � � . �A' • . • - . . � 0�• • '. . `►:•-c �l ._ �� � . � _ . � -. ' . '� ' ' • . � �.,k. � = � y36 � a� . • _ -. • � ' � � � �*r....� . _ . .. , o , . ' ' G� �,.` . : . . � � . � �- ,. � � . � � J � . • . � .� Q l� , l3 . I - . s��'�`9s�s '��a 7�K,i Z�p� $, y�r. 8 �yu � D.(3ooc , �, v 9 . . ysz � � - �o, ro' ,� . 0� �_ ' i � ��� ���� �������� ������ �1 �� �� a �'� . T� �ria� � fi, 0 Pa�� � 2 7.y � � . �ys�n T�Q� (Table �a) �c� � avu�ed.-1ip��ic;�lfi ��.c.�-dv�,. Id�,�. S�bdivis#an C6 /o•�T'a.� Es�. � Addi-e�slp�i�iion fEv� l�. !/(s . � ���� � L�t � : / 7 (3 � ��onld E's�.�L� � Lo� �. :� c�/�/is,�.4 ' •. • - ', • . . � ...� • . . `•���.'(�:;;. �� , •. :,; •.: :,v •,•�� ..`;,.��, .::�.�. . .' �K.. �:: . . . . �. :.- . ... ... �L1.J•��.�� �� '.:.. ti•• �•.;:.. :.. •. ;..,; . . . �... ^. .. '.��.:..• . ?:��-:�..:�:.:J��,�.�.�!� . �.]17r:19'.7Ji'7L�4SY��'-n`��"n-n�� ' . . � . .: .: o:. ' ,-.. . . :: .; ....: . . ... :.... . . . . .. 7�,� . . . . •.:.�:.. •.�'"'""•��5.'�'..�d91::�' `� 1Y:' ••,1p, . . � •,,.: . ,.:. :., .. .. • .:..:.>: , . ; �-•,�.3L�3�: : �+ 1L�., �'�+ �B.lyIIT �.'L��E S}E�+ A'�`�A��+ � �Lr'�1�T �+`��i �+ LL ,�I�+ �.A���J'�' Tax Map �� Applican�� Subdivisi Location: Parcel # �1� Tou�nship: _ �� t`. . �l-�o -�?(` � '�ype of ��i�r 5ea�p�y: Y individual _ Community Public �ec�uan�ement�: Site Approved By: Grouting Approved By: ,� t� yc c�7 Well Log: ,� � Pump Tag: S Well Tag: � Air Vent: � — y�'�% Hose Bib: � Casing Height: Concrete Slab: � � Liner: �Installed by: Depth set: _ Grouted: I�ate: Watea� Sample: Well Driller: 1 Well Approved by: *'�*�See Ati�ched Site Sketch*��� Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems. �� Wells must be at least 25 feet from any building foundation. Other canditions: Date:, /l—�g—�7 PC�ID rev 01/27/0� :- _:., • -- --� Ar ,�.;.,<.; -- . - - �- .�_ _-� �; : •._: 222 /�{'/� "��F y' . A'?Y r.� �'..�v � •.� '•}�j -� + �'L : . �!YYr�VT� iRJ � / -/ l / • �--.�``-�-� �:�- ^� =:�.����..�° � .. _ � ::.�. . �v ,- - . � . �,�,� =- - � A:�:- :::�=:�:-� ���- -...- -� � c� �� �,�.,�c � n���-�� ::.: _ t��:_ :. w:� �� �'��Y:::. _.-- .... �. . .._.... ('��,��� 9 . _... ��-`za.=�es���o,�:���— �':'��':: • ��saa:�,��a:.: L"Xs49�zJ lJUWII�A°J 1 r �(�1 r�""� . • - - - . . . ( Location- Subdivision: Grout Log . " Taa Map � Parcet # Z 7�/ Lot # - WeII Constradion Distance From neanesi Propeaty L'me (Minimum 10 feet) j o'�- Distance finm Septic Sysbexn (1VCnnimum b0 feet) irb (7 'Total Depti�: Z� o ft Yeld: t o - C'sPM - Statie Water I.eveL- 2� $ Waier Bearing Zon� Dept� ( vo $ ft ft ft � . nepi�: From . e� ro �_ $ n��: b'l y m� . � c�� s��,.L�_ . - W�� ���� � � � � g�� �o� �a� 12 m � / Drive Shoe: • Yes No Any problems encountered while setting casvng9 _yes �/ No If "yes" give reason: -- - • G�ut: . Neat SandJC�t � Concrete Gra.vellCx�ent _ --. Annular Space Width • mche.s Water um A�ular Spac� Yes �. No •- Meti�od of Gmu� Pu�ed. Pressitt+e � Poured ✓ Depth r= to ?� Ft Materiats IIsecL � - No. Bags Portland cement " Weight a� 1 Bag Pounds . _ If mixfime (� gravel, cu�ngs) - Itatio to -� ID plat,e�✓ Yes _ No 4 a 4 slab �_ No Liaer: " - ' ��� - -�. Date InstaIled: Gro� �nsfalled by: - D�g � - I.ocation Drstwing . [ hexeby c�artify th�t the abo�e� iafa�ati� is cornect an�d t�at this well was coa� in a� wi$i regulatian.s set fo�h, by the Peison Ca�mty Hr�.lih Depar�at � - - �adire of Co�rstcbor ID# � `2G� Daie. � � ��-r�� , � v _ . . Pamp Ias�l6meat e� �an co�: ��e . lr'� ( � sr� R�� rr„�: �.b � t �P �p�: v $ staac wates Level: �S- $ �%� � 'amip Mak� & ModeL- G��: (�a e_ -% r 5 Pump Size a�d Rafm�-_��P �_ 8Pm r�bY �Y �� P�P was inst�lled an�d the well he�l �complded acx�dmg to ti�e Person Camiy Well Rules m effect xi t�is date and ffiat a copy af t�is record�as 1�u p�rided bo-t�e well owaer_ . PamP IastaHer i3ats: � - °/ '� � PC� rev QU27/04 i� �� �� ,� C� d,P. ��,.Q,�,.� . ��S 1 l l t;l �"�� �/'�A �r��,7 r.Z r� '�e' ������ j ��� � � � -�� -� � ��- � �.�� _I _� � �s �� � t,/�.}tn 1 / �