A40 281::.
.f
Amount paid
,. i�eceipC 1� ' 1
,
7
Y �
�a ����,�-�°,
�'
� XmQrovemencs Pecmic (Establishcd/Recorded L.c
✓mcuovements Permit (Unrecordcd Y.at)
� .
,,.... Impco��mencs Permic (Ivinbile Hame Repiace)
_ Improvcmcnts Pcrmic (Addition) �
a-�a-� �
Dace
.• w.rJ:!7+'��'� w �A :T'
.. �h�_^':..:aa.:�.Y.'1�siL.i'.•. .. .
_ Rcinspec�ion oi Eziscing Systcm (Loan Closin
,r,,,, Re�ai�/Rcplace existing Se�tic Systcm
�,.,,, Pecmic for New Wcl l
_ Replaca Existing Wetl
�
nit �eques;ed by: .
?caspective ownc:: e
s: .� N�� �lv,^a
om� Phonc #: " � - - � �
usiness Phone R:
, 7. Dimensions or Pre�oscd Suuccurc:
� W icth: '
Dc�ch:
--- 8. What tygc (if any, additions, cxpansions, o�
-�-- raplacemenc is anticiaated to thc stnlcture or facility
— that this scwa;e disaosal system is intended to serve'
N�me and addre s oE c::rrent owncr: 9: Wate�t ,su�° ty cy pe:
�', �c �n privatc�d : public ❑ communicy Q spring (�
' � r. l, Are any wells on adjoining property?Yes ❑ No �' '
a°o� � b�ro , iY C ,� ��� 03 If so, idenufy locacion:
Property
Ta�
Parcel#:
Townshi
. Lot siu:
r
.' Ditcccions to Qroperty: State Road #& Road
��tIlCS..tr�C- , , 1 n � � /
0
0
. Number of occupants or peaglc to bo served:
la. Type of scruccurelfaeiliry: Proposed: QExisting: (�
Tyge af dweliSng:
Fiouse:��Mobil� Hame: Q Busincss: ❑
Typc of busincss:
�Number of Employees:�
Number vf bcdrooms: �
C�a,tb$ge Disposal? Yes Cl No �I
Basement? Yes ❑ NoL� If so, # of basemer,t fixtun
CLEARLY STA.KE ALL CORNERS OF THE 1'ROPERTY AND THE CO�tI`IERS �� A�.L
PROPOSED STRUCI'URES•
I heraby make applicacion co che Person County �eaith Department for a sice evatuacioR for chc on•s
sewage disposal syscem fer the above described gmQcKy. I agrce that the co�!ents of this apgiicati4n �te ttuc
and caprescnt the maximum facilitics to be placed on the ps�operty. I understand if thc site is� alteccd or the
incended use changes. thc permit shall become invalid. I underStattd that bcfo[e an Improvomcnts Pecci►it �an
issued, I must present a sucvcy piat oi the pcoperty �o thc Healch Depc. I understand that in thc evcnt I have n
deliveced a survcy plat of the property to the Heslth Dept. within 60 DAYS aFtc< <hc datc of thc evaluation ot
the sita by the Hcaith Dapt. this apptication shatl becomc void and all fccs paid focfcitcd.
g
z � � Signc, Owner or Authoriud Ag�n�
I0 3�dd JNINO� QNC JNINNt7�d 6ELiL6S 6p�£Z 666�/80/Z0
r•
..-^.'� �, .
,. _.._
�
a
w
�
a
� • •
. �
PERSON COUNTY HEALTH DEPARTMENT
fr.
-"' WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
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 # � �d Parcel # %� �
Zoning Township �Q � ,'ve�
Owner/Contractor s���A� /-�a��%�s Date �- ZL ` qQ
Location/Address l-lu �'�' �c1,
S.R.#
Subdivision Name L�a� �'e�4� /�c�c� Lot# �
� pu SEWAGE SYSTEM SPECIFICATIONS
Repair .��.N��:�-H Lot Area l•"?S<k Size of Tank /Uo0
SFD ' Mobile Home � Size of Pump Tank
Business # of Bedrooms �' Nitrification LineS ��x 3' �,� �7-y��11,
�,_�n. Max Depth Trenches /�"
Permits may be voided if site is alter d or intended use changed.
Well and Septic Layout by �� ��`— .1a�� � C-'�ay��
Comments: ,.SEc Gou�'�- a�s � 1' c'. A.
Date / -- y- 99
ell Permit Paid
�blic
te Approved
ell Head Approved.
routing Approved_
Comments:
� ��os, Approved by
WELL SYSTEM SPECIFICATIONS
Semi-Public Required Slab �
Replacement Air Vent _�
Required Well Log
-Y .W I��q �� l WellTag ��
Date (�i� �qq Installed by�,;r Il4�SL� Approved by.
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
A�IN C.
TFIELD
�5 P 229
��/NS
�
/�h�� �
,
/
J
3 a
_ ►-
��
� �-
°p o
��
a �
��
z N
NS
is
IS
E 1 CONTROL
p CORNER
THIS !S A
TION, SALES
� NS
,� a
NS
NS �
NS 6 NS
NS
3'
�o •�
IS
A�'i
NS
%
1.16
ACRES
� R�1� 13 NS 1�
SR �__ �_�60-- ----� r,s ,o "S " 12 Ns 3°:
_ __, _ _ — - - NS • .. N06'00' 11 "W � NS IS �;.(
�— 225.00' 30.00
NS N05'S5'43"W
248 . 54' _ _ �.-- - ' —� IS . �
� rn
30. 16 _ �_ -' .
__�- 1�� T� Cl � o �} rn
I S 1� v t+r i u, � �.
►�` ��, , � � � o N 1 .13 �
l
N ^' � �' � w � '- � ACRES
�l W QI O 0 IZ J� .
� � .
- o
wo ' � �� �� � �
.o � � �-- 42 . 39' -�
� � Sep�''� �' ;
� r ��cl '%�' �rn 187.69'
� 4 r IS
iD� �E(�ci� INS � 225.00' TOTAL l0T 5 $07'27' 4 E
•55�43��E IS
� IS v, v IS S05
22, I S S05' S5' 43"E �� �.o o i
�85' ��E � _ 1
5�6��3,�� I I I
IS
SAMMY B. HAWKINS
0.6. 198, P. 602
�..v %L UQ % l�'� y., �-tc«}
I, (WE) HEREBY CERTIFT THAT I AY (ME ARE) THE
OF THE PROPER7Y SHONN AND DESCRIBED HEREON,
CONVEYEO TO A(E (US) BY DEEO RECORDEO IN THE
COUNTY REGISTER OF DEEOS OFFICE IN 800K ____,
AND THAT I fwE) HEREBY ADOPT THIS PLAN OF SU
WITH AIY fOUR) FREE CONSENT, ESTABIISH THE MIN
BUILDING LIHES, AND OEDICATE ALL ALLETS, MAL
PARKS, 07HER OPEN SPACES TO PUBLIC OF PRIVATE
FURTHER, I fME) HEREBY CERTIFT THAT THE LANO
ON IS MITHIN THE SUBDIVISION REGULATION JURI
PERSON COUNTY, NORTH CAROLINA.
STATE OF NORTH CAROLINA
COUNTY OF PERSON ___________________________, �g____
�
. 9
,� S
NS .NS
NS �"""
7
� 1.1�
ACRES
0
�
�r
..
�. . 1a�.Z2�
►�
� 6. �3 � �2
5�
'1♦•
� . . . ... ��:>
' / �
so R
SR 11�� ___
_ _ ..�.-
__
— — + ~ NS � . N06' ��' > >
NS N05'S5'43"W
2��3 5`�'
30.16'
. _ _ .-
IS
�
225.00
� _ .y---
.� -
_..
- ��,� i"" '� �
� � p� �o ` —
t �
��1 NT 1 � � C
N IL) � cp �ii .
J V' • � � �• N H
ap ��.5� � a�,�a�yv, Q p 0 Z
� N " .
w o _..: o , � .
� u yzi5 n�'cli5 nb� � �.j i
. � �i ��ii n�'l��i�5 �� �i�ir5 � � = — 1 • .
1 — �
_ � �a� � �
�� �,°�� �� 1�� � ���I��i ►a� ���l��i �S �
�����,5 „�/ ��s « ���� ,��°l� �� „e(�►�� G .Lj� Z �
b-r�-� i � �
Z�bl — �-�'
poo�- sld � �
bb_�-� NS 225 . 00 � ,
1i.�a�J 1?�d�� � .. � ..� �..� � �—.
. � �� E � I S �� I S S05' S5'
IS S05 55 43 �� ..
� o � �
. � � � � I
I I I
•
. •. � :
Date� '
Owner. � _ ,`.�iY,
Location/Directions:
Jubtiivision Name:
Drilling Contractor:
___ _ _ _ _
PERSON COUNTY ENVIBONMENTAL HEALTH
WELL LOG
SR#
_ � - .��.�
• - ` % t,
• J�
. . . � • .
llistance from Nearest Properry Line lO Distance from Source of
Pollution (O� '�
Total Dep.th: J 7� _ Ft. Yield: r-�_ GPM Static Water Level Ft.
Water Bearing Zones: Depthc.�_Ft.Bo � Ft��Q_F� �'�.
Casing: Depth: From O to�_Ft. Diameter: Inches
TYPE: Steel ' Galvanized Steel ✓
If Steel, does owner approve: Yes No
� Weight�: - Thickness: /� Height�Above Ground: 6�� Inches
Drive Shoe: Yes ✓ No
Were Problems Encoun[ered in Setting the Casing? Yes No r�
If "yes" give reason:
Grout: Type: Nea[ Sand/Cement_ ✓ Concre[e
Annular.Space Width Inches
Water in Annular Space: Yes No
_ .. Method: Pumped . . -Pressure � • 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 �
r�
I HEREBY CERTIFY THAT THE ABOVE INFORM�ITION IS CORRECT AND THAT
T�S WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY-THE PERS0�1 C��i�iTY HEALTH DEPARTMENT. �
� --
�S gnature of Contractor ate
�
.. r
n