A40 2890
�
r ! Amount paid� �J(/�S� r��
�RBC�eipC ��
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� Xmprovamcncs Perrnic (EstabiishcdlRccorded L
� Imasovements Permit {Unrecordcd Lot)
� ._„_,.. impco�emcncs Permic (Mo6iie Hame Rep[ace)
,_ Improvcmcats Pcrmic (Addition)
�
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0^�:2� �'?r ��e'` .:.,���: ;c�w-t�;�:,,�?�;,,,,�''��°�- !��~`�aEer '�
� ...�...,�.'�''' .r.+. v�.C:..M.._,9F':."iiaw "^,�y... _ "Z...nr�`:.'�Ati
_ �CtfQ�Cuifl
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Da te
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Reinsoeczion oi �xiscing System (Loan CIos
r,,., ReoairlR�place exi5tin
,,,,_ Permit for New Wail
_ Reptacc Existing We!!
_ �2CtCf13 _C�1Cri'11C3�
1. Permit «ques,ed by: .
�wner/prospecc' � ownc:'a
Address: �__��r-+�-y_�
,
!�
om� Phonc �:��,6 `� �s6 �-
usiness Phone �: -'�
� �C5i1G14�C
ic Systcm
� Lcad
7. Dimcnsioas or Fro�oscd S�.ruccurc:
Width: , 2 8'
Dcath:_,, �
$. What tygc (if any, additions, cxpansions, or
rcpl�cernent is arcticiqated to thc stcucture or facility
ttlat this scwa;e disansal system is intcndcd co serve?
Name and addre$s oE,c:�rrent owner: 9: Water supoly ty pc:
�/�-�, � G� R� s�-� � private �public ❑ community C� spring [�
S-� ,,,,:�� / /� - A,re any wells on adjoining property?Yes �No Q
/� ,,�,r, � �, a � i�7 3 If so. idcntiEy Iocatiaa:
P
: Lot siza:
. Tax Map#: � � � o
Parcel�: _ x i�g
TawnshiP: �� � `7'� 1 / v `'�
�
.� Di�ctions to proQerty: Stata �toad #& R�ad
lames.,�cc.
�i�i �.
� �,�.�,,.,� � � .
1Q. Tygc of scructurelfaciliry: Proposed: QExisting: C
Tyge af dwelling:
Honsc: ❑ Nlobil� �Iame, �Business: ❑ ,
Typc of bnsincss:
Nutnbcr of Employees:
c af bcd � . .
C�arbage Disposal? Yes � No �'
Basement? �cs C� No ��IE so, # o basemeat �xturG
5. Number Qf excupants or pedplc to be secvcd: ��
CLEARLY �'Y'A.KE ALL CO�tNERS QF THE PRO� �tNERS O� A�L
PROFOSED STRUCZ`EJRk'S•
hereby make application c4 che Person Gounty ��a�th Department for a sice evatuacion for c�c vn•sz
�cwagc disposai system for cha a6ave dtscribCd pcop�rty. I agrea that thc contants of this application are ttuc
tnd ceprescnt the maximum facilitics co ho plactd on the pcogcrty. I understand if thc sit� is� altercd or thc
ntended use changes, the perrttit shall bCcome inval'sd. I undec�tattd that befare an Improvcments p��<< C�n
ssued, i must prescnt a survcy piat af tha property �o thc Healch Depc. I understa.nd that in thc cvcnt I have nc
teliv�ced a survcy gtat of the pmperty to the He�lth Dept, within 6Q DAY3 aFtcc thc datc oE thc evaluation of
ha site by thc HcaltEt Dept� this appli�ation shall becom� void and all fccs paid forfcitad.
Z0 3�17d
' S�g��i Owner ar Auchorized Agcnt
JNINOZ QNt� �NINN'��d 66LZL65 6b ��Z 666t/80/Z0
- -- - -_����- ---
- ° /�� �
��7 s���� ���r�� �rFlo
a �n �, c� u� �d� —
----- b � �—�J
PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAYOUT
Tax Map #: rf'7(�J Parcel # C�O�
Zoning , �� Township T�a� l� f��
Applicant: 1'1 /VLCAN �
LocaBon: iil.tFF 1�00.c� -�
Subdfvision: �Kf 144C�CrCs SecUon:
Qn've o%1d Loton�
Lot: �_
Improvement Permit
A buildinq permit cannot be issued with onlv an Imarovement Permit
New �Repair _ Addition _ Type of Structure 1�}i Water Supply�r�v�p,-�c.l�-I(
# of Occupants �# of Bedrooms � Other .
Basement? �Q Basement Fixtures�(�
Projected Daily Flow: �a g.p.d. Permit Valid For: LYFive Years ❑ No Expiration
Proposed WastewaterSystem ype: Ca�Vell���nal C"�rau,-(�r %F/p��,
Pump Required? Yes �No
PermitConditions:l��� SeI���C ����FF�Atr� lincs S�C��Fbur%����L Focc�da-��c��
. _ � . . . . , . . . , �- - -- - - - --- ,_ ., ._ L ' �' t� ! F��`'y�1
Owner or Legal
Authorized State Agent:
Signature:
.han 0, ns l �5 �
Date:
3—�3- V o,� � �t
Date: �' i 4 " � �
The issuance of this permiQby 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 Permitl
Type of Wastewater SystemConde�-� on a.l Wastewater Flow:�� g.p.d.
Facility Type: MUI�I (C �'i�M� New G� Repair OExpansion ❑/
Basement? O Yes o Basement Fixtures? O Yes C�YNo
Wastewater Svstem Requirements
Septic Tank Size: �, �v gallons Pump Tank Size: N I� gallons
Total Trench Length:5� feet Maximum Trench Depth: � o inches Aggregate Depth:� in.
Maximum Soil Cover: � inches Trench Separation: 1 Feet on Center �
�'n�.il cw �1-,o�,�n on drac�� ,�'Tkcr� i,5 no �oom ��� ��`
otner: rx� �or er�o� �''
W�tl 5� t� on '�h` 5 1°t '�
Permit Expiration Date: � ��'a00`7 �
Authorized State Agent: Date: ""� '�D
The type of system perm tted ❑ does Q does not differ from the type specified on the application. I accept
the speci�cations of this permit.
OwnerlLegal Representative Signature: Date: ��.� G/
�
PCHD, rev/ 10/12/99
Application #:
Tax Map #: � 4
Parcel #: ag`I _
Person County Health Department
Environmental Health Section
� a0. ��-�- SITE SKETCH
ntiv.N
' „ .. t.� �� k�� �S
Appl'cant's Name
,
Authorized State Agent
QaKri d c ��r� � �
S bdivision/Section/Lot#
��—�
Date
System components represent approzimate contours only. Tlte contractor must flag the system
rior to be innin the installation to insure tliat �o e de is maintained.
`
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Scale: � '� �
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SPC�, rev. 10 1 � �
�� � ��
� ._._
� . � Person County Heafth Department
• � Environmental Health Sectton Z � �
Tax Map �: i� �lv � �:
Znning: � Tovmshlp: �� �rV Cr
Subdivlsion: (J�e • /�Gr'�'S Secticn: _ Loti ��
pppl[ca1i� �iv�rny �GicJ���.S
,
�.00�Otf: ,�� l�l � �U S�l h(.k .��Tu �n h� r.
� �pe�ration P�erm it �
System Type (In Acxordance W'ith Tabie Va): ��-
THIS SYSTEM HAS BEEN INSTALLED tN COMPUANCE WITH APPUCABLE NORTH
CAROUNA GEiHERAL STATUTE3, RULES FaR SEWAGE TREATINENT AND DISPOSAL,
�AND �ALL CONDIT10N3 OF THE 1MPROVE�AAE1dT PER�AIT ��AND CONSTRUCTION
AUTHOR!?A ON � � �
� .-/�� - °�
�k � Authorized State ant � Date
� .� �a /
�—� �K,`– o� - �',c�L
/ ��2`'
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6 i.s`
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7
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�:.
PCND, rev. 10I12/99 .
Person County Health Department
Environmental Health Sectio�� � V�
Zoning: Township:
Subdivision•
���i d e ►"�°S Section: Lot: ��
Applicant: . nhnnti +� I� h-S . �
I,.,OCS�OII: ��� K�1 '� Id1/15��v, Lh � I(it� lL� Y►�h �✓1r"
Operation Permit
-
1. LOCATION AND SEPARATION DISTANCES QS
A) System meets .1950 setback requiremen�s ,
B) Distance from system to any wells :
C) Distance from septic tank to foundation -
D) Distance from system to property Iines � h� %� -
• 2. SEPTIC TANK �-
A) Visually inspect the exterior waUs and top of the tank _�
_ B) Visually inspect the interior walls, baffle, tee, filter, riser, lid.s, air vent,
bottom, and water tight outlet y�'s "�
C) Date of tank manufacture - a�i- o! •
D) Tank serial number >� Q '�s
- - E) Liquid capacity of tank � �3 /otsd -gallons
3. SUPPLY LINE TO TR NCHES
A) Grade ntwl (1/8 inch per foot mirn um
B) Material suppl I�ne s constructed from _� P��
C) Diameter
D) Length � 6 �
E) Distance from tan o drainfiel distribution device
4. DISTRIBUTlON DEVICE(S)
A) Type N�
B) Is Device water tight �
C} Distance from the distribution device(s) to the trenches /� g--
D) is the device on a level foundation /L'�!�-
E) Ooes the device perform according to its design specifications _/�('�
� Recard the inlet and outlet elevations /t/A--
5. NITRIFICATION FIELD
A} Trench depth �_. inches
B) Trench width � inches
, C) Distance between trenches `� � 0 n ��
D) Number of trenches � I � �
E) Length(s) of trenches � 7 ,'7 �{ ,�? 0 I,S�3
F) Aggregate depth � in hes � 5�
G) Aggregate material and size
H) Record septic tank o tlet elevatian ;t� a- �
I) Trench grade e i� (< 1/4° per 10') .
J) Step downs
a. Minimum of 2' of undisturbed earth y Q� �
b. Proper rise over step down ��_
c. Sofid pipe used C� Qe
d. Elevations of ste down �aw�k (Record elevations and show on as built)
See "as built" plan on attached sheef.
PCHD, rev. 14/12/99
PERSON COUNTY ENVIRONMENTAL HEALTH
'' PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: ��1 � Parcel # �� �
Zoning
Applicant: ✓�mmy j—{-ct.c,�kl �
LocaUon: ���'�'�r ��0.�
Townshlp �Ia_L !� � Ve r
A V �'
Subdivision: va~ rl a ryc � � �� SecUon: Lot:
Well Permit
Tvpe of Water Supplv: .�Individual Community Public
ReQuirements•
Site Approved by ��-- �o 0
Grouting Approved by ' o
Well Log r
Well Tag
Air Vent �
Hose Bib �
Concrete Slab
Well Driller: � � ^��
Well Approved By: � '' �
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:
PCHD, rev. 11/29/99
��,,.-� ��%�!
-�.. _
-�-�-�
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date: u -a9'- o! '
Owner ,�_� .. -� D�-�-'�l�./��`^.b SR#
.�
Location/Directions: �
Subdivision Name:
Drilling Contractor:
Lot # /
WELL CONSTRUC'I'ION v
Distance from Nearest Properry Line ► v Distance from Source of
Pollution ( G o
Total.Dep.th: /?-d Ft. Yield: /'oD GPM Static Water Level aZ.S-" Ft.
Water Bearing Zones: Depth a1� Ft. � F� � F� �t.
Casing: Depth: From 6 to � 3 Ft. Diameter: Inches
TYPE: Steel - Galvanized Steel
IF Steel, does owner approve: Y�s No
� _� Weigh� � Thickness_� '� Height�Above Ground: /�/ Inches
Drive Shoe: Yes �/ No . '
i
Were Problems Encountered in Setting the Casing? Yes No � �
If "yes" give r�ason:
Grout: Type: Neat Sand/Cement / Concrete
Annular Space Width - Inches �
Water in ATuiular Space: Yes No
_ .. Me.thod: Pumped � - Pr�ssure � Poured � - � - � �
Depth: From O to �, O Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag lbs.
If mixtuie (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes � No� � � � �
- 4 x 4 slab Yes � No
I HEREBY CERTIFY THAT THE ABOVE INFORMr�1iON IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C�ui1TY HEALTH DEPART ENT.
� �� �
' �---
Sign turc oE Co ractor Dat�