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A40 279� ; � �, ,•-�pelication Date: brtiourit Paid• • Receiat #• Person CountY Health Department E�vironmental Heaith Section . APPLICATION FOR SERVICES Tax Map #: Parcel #: IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED. CHANGED, OR THE SITE IS ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. 1) Pertnit requested by: (Ownedagentlprospective owner):�i- O I.�, Home Phone: Ni /+ Address: 3 O v Business Phone: (331J5'a3� SOS7 3 2) 3) Name and address of cuRent owner: �a.. � 0 Property Descriptiom Lot size: •% 3 Township: ��i y2/v Directions to the property (Including road names and numbers): �o� -f� (Z 4) Proposed Use and Structure Descriptio�: answer each of the following questions: a) Proposed'�, Existing � b) Stick Built �, Modular �, Single Wde Q, Double Wide c) Number of Bedrooms: � d) Nu er of occupants or people to be served e) Basement: Yes ❑, No�ilf yes, # of basement fixtures: � Garbage Disposal: Yes 0, No� / g) Oimensions of Proposed Structure: Width: � Depth: -b� 5) Water Supply Type: Private`�.(new j�..o� existing �), Pubiic 0, Commun'ity �, Spring 0 Are any wells on adjoining property? Yes �( No O If yes, location 6) Piease Indicate Desired System Type: (systems can be ranked in order of your preference) �Conventionalz /`_Modified Conventional _ Altemative Innova6ve Other (specify): �0 � � CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY. STAKE THE CORNERS OF ALL PROPOSED STRUCTURES. PLEASE ATTACH SURVEY PLAT OR SRE PLAN TO THIS APPLICATiON I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposai 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 property. I understand if the site is altered or the iMended use changes, the permit shall become invalid. I understand that a appl' nt, I am responsible for identifying a�d martcing property lines, comers and making the site accessible for the pe nnel e Person County Heatth Department to condud their evaluations. I understand that I am responsible for notifying the alth D ent if my property cont ' etlands as designated by the Army Corps of Engineers. ' /-a�-dC� � O er or egal Representative Date PCHD, rev. 10/12/99 : . y . � . � � � �UJ',q� , \\ / NF .� ' . . - < � `� V . . . . ; 1 Is . � : � . � ` NF 1 : G2 . . � � �; _ � ,. � ;�s % , ACRES . 8�s � , , _ o, � , � s� � ,�, ��:. ::/ 6 O O �'f qs� ^' ;`� , �� O •. J� ry �� . � � 60 � p� . y� . �,� � . :: �ar .�s, '�' ��6 � I! I l L � S SAMMY E3 .. IiA►YK I NS ,. _ �! l/:� :, ;`�� 4s,�o,. �� '�'c� '�, o.Q: �sa. �: soz .� ,�,t. � NF F. NF ?2. D� . .1N5,ar�r. �.� 1S 28 IS . �7 S. �/ r,s . _ . . � . . . � , . � c�° i s . 30 ' � . NS �� NS � , \ . . � . NS 1 w J` `� j �C� .�c. . � '� . � . °� : . • — 4. .< �3 �.o�� '��5 �ss• ��, �h' :� \ �--"- NS �1 � S `. ^ iJ�.�� '� b�o ,��W,. W5 " 1� , NS. N�S � ��`r �� a,,c>� ��. , 30.00' � :., `�0 .� .� ��b - - r�n� v, �, . . i �-�� , � _ � � �� . -:- -- 1 s � `L . . a, o � s t� � � -� • ! S �•(� s o� K 1 Q t� G ' L� , � Ul N t � , O? ' . !j� �/ �G�• � �,, , � <�-�P_ pg�r � � �. , ,�.�, r � : , . yq i ba. J' a . � � i' . . �G '�r 6 A . ' S � � ��/-'"'li � � �; �' i � ° ,'1° � • ti, � `D "15, . � r y � ��j�: 1 j , ,. � •1.9 �-� ►CRCS � o° �•:�'. �� s' �s . � 1 � , 9�.E. . � . � .. IS 0.��,� . ,. , . , 52 ; ' 1 E',7 .69' �:S ; ' ' _ 50.�.27 � AA"E:. . . � pT AL C0T • 5_ _ _ ;i0' , �55:`i3��E 15 � � ' 1JORTH CARULINA PERSON COUNTY , ; e�. � l.---- NEAL_ C_._ HAbILE,T1 ---•' CERf IFY THAT iFIIS, � ,. • VEY CREATLS A, SUE3DIVISION OF IAND.YYITHIN. . , ,. • , . SAA�MY B. HAWKIfJS , . SUR�ncn►t,_.;..r_c��icy�v_�._..�t..i:r�FS...�.�lY.:.:I:lM1q:.ANU:..SF_/�L .If:i1S. , . _. _. ...._.. _ ,.... _ , , , , . _.... -- - - . � � � • " ♦` 7 ' �. •� . . PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAYOUT Tax Map #: 1 I � � Parcei # � / / Zoning Townshlp I �at �� v u Applicant: ��mL I ' , � x LocaUon• 1-f(.LFF ItO�a Subdivision: �Krlfl�lG /TCiCS SecUon: Lot: � Improvement Permit A buildincl permit cannot be issued with onlv an Improvement Permit New ✓ Repair _ Addition _ Type of Structure �� Water Supply�r�vc�tL W �( ( # of Occupants `T # of Bedrooms 3 Other • Basement? \��Basement Fixtures�� Projected Daily Flow:�0 g.p.d. Permit Valid For: td'Five Years ❑ No Expiration Proposed Wastewater System Ty e: ��1� �.(lt1`Ona I Czruv� tY �1. Pump Required? Yes ,�No PermitConditions:�/��Lt E��on 5itc Fo�lavou-t� I�C«�v��C /(�� OFF prOOtTE� 'nFF 4,�„ Idr Owner or Lega! Authorized State Agent: iv/1 S- ,C� Date: � —�� Date:d'/ b' -C� (� _ - �, 3. The issuance of this permi by the Health 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 �AnU[�l'E�Orla-1 ,�'.Wastewater Flow:.�(e(7 g.p.d. Facility Type: M�b� �C �OmG Basement? 0 Yes o Wastewater Svstem Requirements New �Repair OExpansion ❑ Basement Fixtures? O Yes C�I�o Septic Tank Size: �/ � � � gallons Pump Tank Size: N/ I� gallons Total Trench Length: �� feet Maximum Trench Depth: � o inches Aggregate Depth: c� in. Maximum Soil Cover: �O inches Trench Separation: � Feet on Center Other. �� I I ��✓1Z.S ar1 C'0�1"�l�" Permit Expiration Date: '� � ac�o5 Authorized State Agent: �( 6 10C„ Date: «��-O(7 The type of system per itted ❑ does oe not dif�r�om the type specified on the application. I accept the specifications of this permit. Owner/Legal RepresentativeSignatu e: � ate: �`�� PCHD, rev/ 10/12/99 Appiication #: � � � Tax Map #: a 79' Parcel #: Person County Health Department Environmental Health Section SITE SKETCH �� QaKr�dRc F}crc.�s � �umc. Mc�.x Appli ant's Name Su division/Section/Lot# � o� -1�"Oc� Authorized State Agent Date Svstem comvonents represent approxin:ate contours only. TI:e contractor must flag the system � „_� o . Scale: PCHD, rev. 10/12/99 Yt°� �� Person County Health Department A Environmental Health Section Tax Map #: _,�„'T � Parcel #: o� � 9 Zoning: Subdivision: O�Kri ciq C. ��tS Applicant: Location• Township: ��"� iZ t �P C r Section: Lot: � O eration Permit 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 HORIZATION. ��I—Ov Authorized State A en � .�..��2c�(�P � f�5'�0 � �� s�a�a�w- �s' t�' L 5` i► 5'$ �,l �'� .i Z `? i G,3 a,, Z � �3 gHf L+n G �,� 11�5 � i L.� ^ � j1i Jl �� AC 3 - Tax Map #: Parcel #: PCHD, rev. 10/12/99 Person County Health Department Environmental Heaith Section �� e� Zoning: Township: Subdivision: �.Krr �l t%} CreS Section: Lot: � Applicant: Location: Operation Permit 1. LOCATION AND SEPARATION DISTANCES ✓ A) System meets .1950 setback requirements B) Distance from system to any wells i 00' C) Distance from septic tank to foundation 1 S` D) Distance from system to property lines I O' 2. SEPTIC TANK A) Visually inspect the exterior walfs and top of the tank _�� B) Visually inspect the interior walls, baffle, tee, filter, riser, lids, air vent, bottom, and water tight outlet �_ C) Date of tank manufacture ��`1 �� q D) Tank serial number �'f(3 I`1 a E) Liquid capacity of tank IooO gallons 3. SUPPLY L1NE TO T NCHES A) Grade � (1/8 inch per foot minimum) B) Material supply�l�ne is constructed from �i� 4a P1�C C) Diameter 3 D) Length �"' �� E) Distance from tank to drainfield/distribution device . 4. DISTRIBUTION DEV C S) A) Type � � � B) Is Device water tight C} Distance from the distribution device(s) to the trenches D) Is 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 ►a inches, C) Distance between trenches � D) Number of trenches �✓' E) Length(s) of trenches y; 1(�S {/ GS' F) Aggregate depth 1a inches G) Aggregate materiaf and size # J H) Record septic tank out et elevation I) Trench grade (< 1/4" per 10') J) Step downs a. Minimum of 2' of undisturbed earthz/ b. Proper rise over step down � c. Solid pipe used � d. Elevations of step downs �(Record elevations and show on as built) 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 #: � �� Parcel # � I " Zoning Applicant: �D me' ��X LocaUon: Township 1 �—"" � � v�'` � 4 Q�,Krid�c Rcrc.s Section• Lot: Subdivision: �� Well Permit Tvpe of Water SupplV: � Individual Community Public Reauirements: Site Approved by /�� 3 6-� Grouting Approved by /ls� S� Well Log ��' ��s� Well Tag�� -� -�v _ Air Vent �;�� 6 -�' Hose Bib �?� .3 �-� Concrete Slab�-�` � 6'� Well Driller: ��n-ett��- Well Approved By:,/.�� ,� Date: 3 ��'" �' **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: ' From d �-tci� ►a' Fram � i� p�G(�i s.va-1p� iG„ PCHD, rev. 11/29/99 . � � . . .. � Date: � � Owner. � � c�, Location/Direc[ions: PERSON COUNTY ENYIFtONMEHTAL HEALTH WELL LOG ' SR# . ~�ur�.� � . . , S• Subdivision N�une: _____ -� � _ �� Lot # Drilling Con�-actor: - � WELL CONSTRUC"I'ION � Distance from Nearest Properry L�:n�__� Distance from Source of Pollution_ IG� ' Total Dep.th: 1�Q Ft. Yield: �___ GPM Static Water Level ��_t=�. Water $earing Zones: Depth�__rt. �_��_Ftj�O Ft_ �t. � Casing: Dept}i: From C� to � Ft. Diamcter:^- ��jnch�s TYPE: Steel � Galvanized S[eel � If Steel, does owner app: ove: Yes No � Weight: T}tic};nesy 1�g Height�Above Ground:__J �__ Inches I?rive Shoe: Yes ��No - Were Problems Encountere� in Setting the Casing? Yes No_�� If "ycs" gi�e r�ason: Grout: Type: Neat Sand/Cement �� Coricrete Aruiular Space Width Inches Water in Annular Space: Yes No _ .. Method: Pumped � - Pr�ssure � Poured_L� � � �. . . Depth: From :0 2 Ft. � � Materials Used: No. Bags Portland Cement Weight of .1 bag__lbs. If mixture (sand, grav�e1; cuttings) - Ratio: co �ID Plates: Yes v No � � �� 4 x 4 slab Yes�No � u I HEREBY CERTIFY THAT THE ABOVE TNFORMATION IS CORRECT AND TH AT THIS WELL WAS CONS'�RUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH By�THE PERSON C�ui�'1'Y HEALTH DEPARTMENT. C -�--- ignaturc of Contractor Da�c ►.. u