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A40 278� � i ' !�"""' 0 U R C ceipc , ;�. • , l � � � � , w � ¢ a paid f��U� � ' i �� ag a� 02 rovements Parmic (Estabiishcd/Recorded Lo Imp.covements Pcrmit (Unrecordcd Lot) Rc �2 - (�, -� 9 Da te r>,-••- . a;1� �: _.. �/'„ �n oi Exiscing Systcm (Loan Clos lace oxi5cing Septic Systcm Impcaverncncs Permit (Ivfobile Kame Repiacc) r,,,, Permit foc New Wcll Ymprovcrnents Permit (Addition) _ Raglaca Existing Wel! �. ... �� s �� ..trZ '•�w�� . .ieJ<. Z 3 . Q `��'.. ..,. ��..�YM N' !9.. H `�� y(r�'T' !<�!�. Yl JL �;;;.�,�w:.:^�� ;�..,�`;��,.��,� aEer� _P�'�i�"be'�oll��teci:.� ::�='::� .r.:�� ..�...:r.e.»^:a�:•:s��. _ � �._.�.. _.n.. _ $acteria _Chemical _ Petrolee�m r� � Pcs[icidc cit reques:ed by: . r prospectivc owne: ress: � � y � � v� ome Phonc #: h - ' - � usiness Phonc R: Namc and Tax MaF Parr.aI�: Townshi oE c::rrent owncr: � . Lot siu: � Dirccaons to property: State Road #& Road ames,..�cc. , , , „ „ n i Number of accupants or peoplc io b� servcd: 7. Dimensions or Praposcd Suuccurc: W icth: �.,, Lcad 8. What tygc (iE any, additions, cxpansions, oc radlaecmenr is anticiaated to the stcucc�re or facility that this scwa;e dis�osat system is intendcd ta serve' �In,�R' - 9: Water sug,oiy typc: pcivatc�ablic ❑ communicy �1 spcing �1 Ar� any w�lls on adjoining praperty?Yes ❑ Na � If so, identify locatian: IQ. Type of scructureJfaeiliry: Proposed: QExisting: i Tyge af dwetl�ng: House: ��Mobile Home: Q Busincss: ❑ Typc of busincss: Number of Employees:�„_ Number of bcdrooms: � C}�urbage Disposal? Yes ❑ No �l Basement? Ycs Ci NoL7 If so, # of basement fixtur� CLEARLY STAKE ALL CORNERS QE T8E PROPERTY AND THE CO�t1YERS 0� ALL FROPOSED $TRUCTURES• I horcby make applic�tion to the Persoil Caullty' ��$�th Departm�nt for a sitG evaluation for cha on•s sawagt disposal system for the sbove described proQcrty. I agrea thac thc �oatents of this application ate ttuc and ceprescnt the maximum faciiitics ta be plae.�d on the property. � undersiand if the sitc is� alteced ar thc intended use changes. thc permit shalt bacome invalid. I understattd that bcforo an Improvcmcnts P�cm�t �n issued, � must present a sucvcy plat of' the property co the Healch Dept. I understand that in thc evcnt I have n detiveced a survcy plat of the property to the Health Dept, within 6U DAYS aftcr thc datc oE thc evaluation ot the site by thc Hcalth Deg[.. this application sh�ll becom� void and ali fccs paid forfcitcd. g z Signcl0wner er Aathoriud Agcnt •��. . ' �-: . Z0 3Jad �JNINOZ QNd r�NItJN'+71d 66LtL65 6b �£Z 666Z/80/Z0 t a PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM 1 Tax Map #: / � � � Parcef # � � � Zoning Township �uL 1C 1 Uu Applicant• d%�C�l►IG-X LocaUon: �U�r ��o Subdivision:P�Krf c+-MG /�[CiCS SecUon: Lot:�_ improvement Permit A buildinq permit cannot be issued with onlv an Improvement Permit New,�Repair _ Addition _ Type of Structure�}} Water Supply �I�a"� �`�� # of Occupants ? # of Bedrooms � Other . Sasement? \�O Basement Fixtures? Projected Daily F1ow:�•� g.p.d. Permit Valid For: �Five Years ❑ No txpiration Proposed Wastewater System Type: ��n��Or1a� G ra-"'�-b� � Pump Required? Yes �No PermitConditions:MCX.� EI-�S Drl Ss�L Fo� layou-t� K�Q ,S�'�F�C lD� a�F p�Qtrty I in�S,,S'oFFbc�� Idinr� Foc..^a.,.�-:�',-<- �� Fr�m �cF�ic, r'f'ac�►� tVab�c. � Owner or Legal Authorized State Agent: natu �� Date: � �� C-• Date:o�� .. -- �. The issuance of this per t by the Healfh Department in no way guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate goveming bodies in meeting their requirements. This site is subject to revocation if the site plan, plat, or the intended use changes. The Improvement Permit shall not be affected by a change in ownership of the site. This permit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administrative Code. Authorization To Construct Wastewater Svstem (Required for Buildinq Permit) Type of Wastewater System Conuen�� Wastewater Flow: c�Qg.p.d. Facility Type: �� G homc, Basement? O Yes o a Wastewater Svstem Reauirements Septic Tank Size: �i00� gallons New E� Repair OExpansion ❑ Basement Fixtures? 0 Yes C�'�lo Pump Tank Size: N�R gallons Total Trench Length: �TIJv feet Maximum Trench Depth: � O inches Aggregate Depth:� in. Maximum Soil Cover. � inches Trench Separation: � Feet on Center Other: �l��0.I I �� n �n�u r Permit Expiraiion Date: �� b� a� AuthorizedStateAgent: .S�i 6 ��e� Date�"��'�� , T. The type of system permitted ❑ does s not differ from the type specified on the application. I accept the specifications of this permit. Owner/Legal ftepresentative Signat re: �" / � Date: aa�U PCHD, rev/ 10/12/99 Application #: _ Tax Map #: /9y0 Parcel #: a7� Person County Health Department Environmental Health Section �� mc.Max Applica t's Name Authorized State Agent SITE SKETCH Kri d e /-}cres � � Sub ivision/Section/Lot# a�l$ -c�c� Date Svstem components represent approximate contours only. Tlie contractor must flag the system � ��'� �0 � � Scale: � PCHD, rev. 10/12/99 r ��c..� ia' : Person County Health Department • Environmentai Health Section '. r.� Tax Map #: �Y� Parcel #: a%8 Zoning: Township: ��c;� � � �f .�_ 7Subdivision: ,��'Q /�� (h'�� Section: Lot: �_ ( . `� pplicant• � Location• Operation Perm it System Type (In Accordance With Table Va): � THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL, AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION AU ORIZATION. � 3- �—oc� Authorized State Agent Date Tax Map #: �� Parcel #: .1 `� � PCHD, rev. 10/12/99 Person County Health Department Environmental Health Section Zoning: Township: �.�- ' �� Subdivision: � Q Section: Lot: �_ Applicant: Location: _�i � �d- hQCcC� Operation Permit 1. LOCATION AND SEPARATION DISTANCES A) System meets .1950 setback requirements B) Distance from system to any wells C) Distance from septic tank to foundation • D) Distance from system to property lines �,p J- � 2. SEPTIC TANK A) Visually inspect the exterior walls and top of the tank B) Visually inspect the interior walls, b ffle, tee, filter, riser, lids, air vent, bottom, and water tight outlet C) Date of tank manufactu�e D) Tank serial number E) Liquid capacity of tank �0�►D gallons 3. SUPPLY LINE TO TR CHES A) Grade (1/8 inch per foot minimur� ) B) Material suppyl I�ne is constructed from C..CI � V� C) Diameter S D) Length � E) Distance from tank to drainfield/distribution device �_ 4. DISTRIBUTION DEVICE( ) A) Type B) Is Device water tight C} Distance from the distribution device(s) to he trenches D) ls the device on a level foundation E) Does the device perform according to its design specifications _� F) Record the inlet and outlet elevations _��_ 5. NITRIFICATION FIELD ,� A) Trench depth � inches B) Trench width " inches C) Distance between trenches q'f'. D) Number of trenches E) Length(s) of trenches 3� F) Aggregate depth " inches G) Aggregate material and size ,rQ�e H) Record septic tank outlet elevation 3 I) Trench grade SP� ru�} j�_ (_< 1/4" per 10') J) Step downs a. Minimum of 2' of undisturbed earth �_ b. Proper rise over step do n_�� c. Soiid pipe used _� d. Elevations of step downs (Record elevations and show on as built) rq„r„ng See "as built" plan on attached sheet. PCHD, rev. 10/12/99 PERSON COUNTY ENVIRONMENTAL HEALTH '� PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Map #: ! 1�� Parcel # a 7 g Zoning AppllcanL• /'�mL• "�X LocaUon: Township 1 I`^"' ►`� v C I " 3 Subdlvislon: � KI�I � C SecUon: Lot: Well Permit Tvpe of Water Supplv: �dividual Community Public Re4uirements: Site Approved by ,�% .3��a� Grouting Approved by �?/o� S�-�� -�- Well Log �� 3 � _� Well Tag r_,t,��C' 3-c -� Air Vent ��' 3-c �so Hose Bib Gl-��,P �-,�'-� Concrete Slab �2� � 6 00 Well Driller: .� r•��T Well Approved By:_, . f ��— Date: � �� **See Attached 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 conditions: nr� d i-�c..G,. I O' -�p - l � n c �I-e�a.Scrncn��s PCHD, rev. 11/29/99 Date: ' � ' Owner: Location/Directions: PERSON COUNTY ENVIRONMEHTAL HEALTH HELL LOG SR# Subdivision NZrne: _ � , �S Lot # 3 Drilling Contractor: WELL CONSTRUCTION -- , Distance from Nearest Properry L�:n� Distance from Source of Pollution (.�� ' Total Dep.th: I __ Ft. Yield: `Z��__ GPM Static Water Level `Z �-,- �=�. Water Bearing Zones: Depth,�__rt.�-� Ft 12c� Fc._ �t. Casing: Dept}i: From C� to�Ft. Diameter: �i Inche; TYPE: Steel � Gzlvanized Steel � If Steel, does owner app:ove: Yes No � Weight: Thi� :- '�� Height Above Ground:� Inches . I?rive Shoe: Yes No Were Problems Encountered in Setting the Casing? Yes No -� If "yes" give reason: Grout: Type: Neat Sand/Cement � Concrete Annular Space Width Inches Water in Annular Space: Yes No - -. Method: Pumped � - - Pr�ssure � Poureri � - � � � �. . Depth: From C� :o ZC� Ft. . . MateriaLs Used: No. Bags Portland Cement Weight of .1 bag__lbs. If mixtuie (sand, grave ; cuttings) - Ratio: to �ID Plates: Yes `-' No � � �� '� 4 x 4 slab Xes � No I HEREBY CER'IZFY THAT THE ABOVE INFORM�TION IS CORRECT AND TH AT T�S WELL WAS CONS'�RUCTED ]N ACCORDANCE WITH REGULATIONS SET FORTH BY�THE PERSO�I C�Li�'I'Y HEALTH DEPARTMENT. . � c' � -- ignaturc of Contractor a�e