A40 2808
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Amou�t paid 1�0.00
�teceip� � ' la.
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Improvemencs Permic (EstablishedlRecorded Lot) _
Impsovements Pccmit (Unrecordcd Lot)
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imp�a�emcacs Permit (Ivfobile Kome Replace) ....,,
Improvcmencs Pcrmic (Addition) �
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Date
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. . �'h. ^•�.:.a., '%7S: •:iL�n:���.
in oi Exiscing Syscem (Loan Clos
lace czi5ting Septic System
Pecmit foc New Wcil
tace Existing Weii
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t . it �eques;ed by: .
wner praspective ownc:
ress: , � '� � � l�v�
nt:
omc Phone �: o �/ �/- �l ��- l �
usiness Phona R: _
. Namc and �
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. Prapccty D
. Tax Map#:
Parcel�: _
T.��*sn a {� i n.
7. Dimensians or Froaoscd Suuccurc:
W icth: _ ,
Dcpth:
8. What typc (if any, additions, cxpansions, o�
',rcplzcement is anticiaated to the stcucture or facilicy
�that chis sc�va;e dis�osal system is inteadcd to serve'
, ,�,,, �? D/I
oE c:�rrent owner: 9. Wacet sug.oly ty pc:
,� �� � n privatc�puhIic ❑ aommunicy C� spring C1
� rl'1; /l5 /c� _ Are any w�lls on adjoining property?Yes 0 No �'
' C .�� c� � 03 ._ If so, identify location:
. Lot size:
0
.' Directions to proQerty: State Road #& Rogd
[ames...�cc. , , � ,, ,, n /
1Q. Type of structurelfa�iliry: Proposed: QExisting: (
Tyge of dwell�tig:
House: ��Mobile Hame: � $usincss: C�
Typc of busincss: �
Number of Employees:
Number af bcdrooms: ...,
C��cb$ge Disposal? Yes Q No �1
Basement? Yes C] No D if so, # of basement fixtur�
6. Number of occupants or peopl� to bo setvcd:
CLEARLY STA.I� ALL COI�NERS QF TH� PRO�'ERTY AND THE CORNERS �� ��L
PROPOSED STR.UC1'URk'S•
I hereby make application co the Per'soil COuttty ��Ith Depat'tment fvc a sitG evaluation for tha an•s
sewage disposal system foc the gbove described proQeccy. I agrea thac the �oa�cncs of chis application ara ttuc
and capresent the maxinnum facilitics to ba plac�d on tlle pmperCy. I understand if tttc sito is alteccd or the
intended use changes, chc pcc�mit shalt become invaiid. I under�tattd that bcfore an Lnprovcmcnts p���t �n
issued, I must present a sucvcy plat of the property to the Health Dept. I undcrstand that in thc evcnc I have n
delivccecl a survcy piat of the propercy to the Health Dept, wi[hin 6Q DAYS aftcr lhc datc of thc cvaluation ol
thc site by the Hcalth Dept� this application shal! become void and all fccs paid forfcitcd.
�
z � Signcl0wner or Authorized Agcn�
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Z0 3�tid JNINl7Z QNti JNIIJNb�d 66LZL65 6b �Ei 666Z/80/Z0
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75 P 229
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SAMMY 8. HAWKINS
D.B. 198, P. 602
S1ATE OF NORTH CAROI.INA
r —�--� COUNTY OF PERSON
Lo � S �a % 1�� �� �c�
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I. (WE) HEREBY CERTIFY THAT I A�1 (NIE ARE) T
OF THE PROPERTY SHOwN AND DESCRIBED HEREON,
CONVEYEO TO IIE fUS) BY DEEU RECORDED IN THE
COUNTY REGISTER OF DEEOS OFFICE IN BOOK ____
ANO THAT I(NE) HEREBY AOOPT THIS PLAN OF S
N1TH AIY fOUR) FREE CONSENT, ESTABLISN THE AII
BUILDING LINE5, AND OEDICATE ALL ALLEYS, MAL
PARKS, OTHER OPEN SPACES TO PUBLIC OF PRIVAT
FURTHER, I(NE) HEREBY CERTIFY THAT THE LANU
ON IS IMITHIN THE SUBDIYISION REGULAT[ON JURI
PERSON COUNTY, NORTH CAROL[NA.
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B 2947
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT 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 # !7 �Q Parcel # �8�
Zoning Township F'/a � uc�
Owner/Contractor ,SQ � r• �/ � la w�%�s Date S- Z� -`�3
Location/Address /-,���'<' l��.
S.R.#
Subdivision Name d� � /,` qc ,9c�-�S Lot# S
, p,� SEWAGE SYSTEM SPECIFICATIONS
Repair .,�„N�:,,�. �:�� Lot Area % / � /�� . Size of Tank /4�
SFD ' Mobile Home ✓ Size of Pump Tank
Business # of Bedrooms� Nitrification Line �100 � X3 �
Max Depth Trenches �a ��
Permits may be voided if site is
Well and Septic Layout by �. �
Comments:
Date G- 3- 99 Installed by C4��; �
or intended use changed.
T,�.<� �fe✓�v✓
.�,
Approved by,
Well Permit Paid L� WELL SYSTEM SPECIFICATIONS
Individual ✓ Semi-Public Required Slab
Public Replacement Air Vent ✓
Site Approved ✓ l� 3Q Required Well Log
Well Head Approved — Well Tag �
Grouting Approved �/'3u 1t l, - aa-� i ,�!�0� ,/ (
Comments:
Date r� �� Installed by �� ���i� �"� Approved by
0
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 also not
responsible for concealed conditions on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. Neither Person County nor the environmental 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
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; S-s-99
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� Date: '
' Owner. � �
Loc ation/Directions:
_ .. __. . _
_ .
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG '
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SR# ' - � .
Subdivision �Name: __ � -�' Lot #
Drilling Contractor: (,�. .
Distance from Nearest Properry Line l0 Distance from Source of
Pollution . �pO '
Total Dep.th:�_ Fc. Yield:�0 GPM Static Water Level Ft.
Water $earing Zones: Depth �_Ft�_F� �i� .. Ft� ��,
Casing: Depth: From � [o l c� ( Ft. Diameter: Co Inches
TYPE: Steel � Galvanized Steel ��
If Steel, does owner approve: Y�s No
� Weight: � Thickness: l�r HeighrAbove Ground: � t� Inches
Drive Shoe: Yes ✓ No
Were Problems Encountered in Setting the Casing? Yes No ✓
If "yes" gir•e r�ason: �
Grout: Type: Neat Sand/Cement ✓ Coricrete
Annular. 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) - Ratio: to
�ID Plates: Yes � No � � � � �� � .
�� 4 x 4 slab Yes �—No
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I HEREBY CERTIFY THAT THE ABOVE INFORM�'CION IS CORRECT AND THAT
T�S WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH By�THE PERSON C�UidTY HEALTH DEPARTMENT. �
�
Signature of Contractor atc
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