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� Xmprovcmencs Pccmic (EstablishcdlRecordad Lot) _ Rciaspeccion oi Exiscing Systcm (Loan Closing)
✓mcicovements Pccmit (Unrecardcd Lot) ,,,,,� Reoair/�tcplacc existing Sepcic Systcm
Imp�oveme:�cs Permit (IvlQbile Home Repiace) .�,.,. Permit for New Wcil
_ impcovemcnts Pcrmic (Addition) _ Replacc Existing Well
y�. (,�, ..�. .:s s ' � F`"y ,�r� :�-•�."� ,ar »•.���r.":^.:�' �.,
�� A �"M' k'IIR�i:��+�'i�� j��Y.�`��� � � ��LQ��rS H'�•"Yl�n� �~...� ,F ^ if:�w �+y�r1,
.►��r� �.� :�?,`�.�::a�•��"�-,��r�� aEar� _pte�$'=be�G..ioll ,� �d�..���.t.�.- ��. �.�x��•:�:� . .,,,,,,
_� 3CCCC13 _ Chemical _ Petroleum y Pcsticidc �... Lcad
t. it ceques;ed by: .
wner praspective ownc:
ress: __� '� � �-_/��
nt:
0
;omc Phonc �• o �� �/- �� �� �
usiness Phone R: _
7. Dimensions or Pro�oscd Suuccurc:
Wicth: , � 8 x ��
DcptEt:
8. What type (if any, addicions, expansions, or
',rcplacetnent is anticiaaced te thc stnlcture or facility
that chis sc�va;e dis�osal system is intended to secve'
A
Name and addre s of,c::nent owncr: 9: Wacer sug.oly ty pe:
�n _��% •,l� ,n 5 � privatc�ublic ❑ communiry Gl spring ❑
�� �/���� ,��r�ll� rI'I; //s /c�� _ Ate any w�lls on adjoining property?Yes❑ No �-'
_�� �1.60rP � 1Y C .� ��� a3 _ _ If so, idencify location:
, ProQcrty D
. Tax Map#:,
Pa�cal�: _
Township:.
tion: Lot siu:
.� Direccians to pcoperty: Scate Road #& Road
iames.��c- , , � „ „ � �
0
�
IQ. Type of structureJfaciliry: Praposed: QExisting: {
Type af dwellSng:
House: �'Mobila Home: Q Busincss: ❑
Typc of busincss:
Nutnber of Emplcyees:
Numlxc of bcdrooms: �,
C3�tbage Disposal? Yes ❑ No ��
Basement? Ycs C7 NoL�'If so, # of basement fixtur�
6. Number of occupancs or peoplc to be secved:
�LEARLY STAKE ALL CO�tNERS tJ�' TH� PROPERTY AI�ID THE CO�tI`IERS �� A�.L
PROPOSED STRUCI'URES•
I horeby make appiication to the Per'SOA C�uAtj� �BSIth Dep�i'titl�nt fvc a sitG evaluation for tha on•s
sewaga disposal syscem for che above described propercy. I agrea ihac thc �on�ents of this application a,t� ttua
and ceprescnt the maximum facilitics to bc placcd on the pmperty. I understand if thc site is altercd or thc
intended use changes, thc permit shall bacome invalid. I under�tand that bcforc an Improvomcncs Pern1<<c�
issu�d. i must present a sucvcy plat of the proPeriy ta the Health Dept. I understand that in thc ovcnt I have n
deliveced a survcy plat of the propercy to ihe Health Dept. within 6Q DAYS aftec thc datc of thc evaluation ol
the site by thc Hcalth Degc.� this application shaI! beeome void and all fccs paid forfcitcd.
�
t0 3�tid
• �igt�c� Owner or Authorized Agcnc
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SAM�IY B. HAwK I N�
D.B. 198, P. 60:
STATE OF NORTH CAFI
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PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMI'ROVEMENT PERNIIT
Not for waste water system construction. No permit(s) for Constrnction Location or
Relocation Activity shall6e issued until Authorization for waste water system construction
has been issued.
Tax Map #� y0 Parcel # o%7
Zoning Township FI at �i v c r
Owner/Contractor ccr,bar�a. W � n�tcad Date/ —�� q9
Location/Address /� 7 S Turn '� o � �f� FF ��d � /�Opro x i rna-t� f y •
%a m� IL on �Z S.R.#
Subdivision Name C�Kr� da� /�c��s Lot# $
SEWAGE SYSTEM SPECIFICATIONS
Repair.=�,�ada-Ei�� LotArea /. /`/�C SizeofTank��p0 G�1lon
SFD Mobile Home ✓ Size of Pump Tank
Business # of Bedrooms 3 Nitrification Line `i00' x�`
Max Depth Trenches � �8 "
Permits may be voided if
Well and Septic Layout by.
Comments: �/►'lect EN
C�'on � r't'i O/1 S D F Or
or intended use changed.
u
Date �p��— y�'/ Installed by /l� , j,p,LU [� Approved by.
Comments:_I�1txD W� 11 (� 0' plu.5 From Srpt%� Sy.s-�, a�''F�am bu� Idr'ny
�'ounclat;on5, 10' Fi"'orn QrppC��y /;nc5
�l/��G'G%L' - � � �!! �,,� � - „�� � � � . - � �
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 e�vironmental 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:\amiprolpermit.sam O1/95 rev.l.l
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D.B. 198, P. 60�
STATE OF_NORTH_CAf I
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D.6. 198, P.
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PERSON COUNTY ENVIBONMENTAL HEALTH
.�
WELL LOG
D3te: /D- � 9�/' '
Owner.
Location/Directions:
SR#
Subdivision Name: ___ G2�s Lot # �
Drilling Contractor: („� . ��e� y
Distance from Nearest Prop�rry Line oZQ Distance from Source of
Pollution_ lOv `
Total Dep.th: �aU Ft. Yield:_��____ GPM Static Water Level - c� Ft.
Water Bearing Zones: Depth�_Ft.�_Ft� %�S Ft� ��.
Casing: Depth: From_�_to�_Ft. Diameter: Inches
TYPE: Steel - Galvanized Steel
If Steel, does owner approve: Y�s No
� Weight: � Thickness: !� HeightAbove Ground: <�i Inches
Drive Shoe: Yes ✓ No : -
Were Problems Encountered in Setting the Casing? Yes j�to � �
If "yes" give reason:
Grout: Type: Neat - SandJCement �/ Concrete �
Annular. Space Width Inches
Water in Annular Space: Yes No
- -. Method: Pumped . _ . �Pr:ssure � - Poured_✓ ��- �. . . •. - :.
Depth: From O to_ �, c� Fc. . .
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 �
I HEREBY CERTIFY THAT THE ABOVE INFORM�TION IS CORRECT AND THAT
T�S WELL WAS CONSTRUCTED IN ACCORDANCE WTTH REGULATIONS SET
FO
RTH gy�THE PERSON C�Vi�ITY HEALTH DEPARTMENT.
✓ � - ' --
�Signature of Contractor Datc
�