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Receipt �� '
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'�C::^er �'?2.�3•�5 D a t e
LiCATiON F�R SERVTCES
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Services :Requ_"`�"e_.s_ted .. :' . _ : . _. ;.' ., `K , �`":�',��� � -t;'
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Impreveme�ts Permit.(Established/Recocded Lot) _ Rei
� _ ImG:ovemencs Permit (Unrecorded Lot) _ Ret
� I_ lmprovements Pecmit (Mobile Home Replace)
� �_ Improvements Pecmit (Addition)
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�n of Existing System (Loan Closing)
lace existing Septic System
Permit foc �1ew Weil
,_ Replace Existing Well
I. Pernit : equested by: . 7. Dimensions or Pr000sed Structure:
owner/p;ospective owne:/agent: �%��' � �pG�= �'�i�ch: � g
Address: . . 4�- c/�' CS 1-� � Deoth: �°
- . 8. What type (if any, additions, expansions, or
re�Iaceme�t is anticipated to the structure or =acility
t�2t this sewage disposai system is intended :o se��e?
[ome P�cne'�• 3 �f �s��—
�usiness Phone �:
. I�Ia � and addres�P[.c ent owner. 9. Water suoply t}•pe:
/� � private �. public ❑ community ❑ spring C
- Are any wells on adjoining property?Yes ❑ No [�
G � 3 If so, identify location:
. Prope�y Description: Lot size: /� �6 ��-
Tax Ma�: . A � b
Parcelz: � 9 �
Townshio: `� � � r _ r v� /t'
. Direccions to propercy: State Road :& Road
fames,�tc. � � „ /J�
K-�'
Number of occupants or oeople to be
I0. Type of structure/faciliry: Proposed: ❑Existing: Ci
Tyge of dwelling:
House: ❑ Mobile Home: � Business: Q
Tyge of business:
Number of Employees:
Nu . �� � _ �{-� O
e Dis osal? Yes ❑ No -
�asement? Yes No If so, n of baseme�t fixcures:
r- Zl' � `�
CLEARLY STAKE ALL CORNERS O�PROPERTY AND THE CORNERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the PersOn COunty Health Department for a site evaluation for the on-sit
sewage disposal system foc tha above described propetty. I agree that the concents of this application are true
�nd represent the maximum facilities to be placed on the propeRy. I understand if the site is altered or the
intended use changes, the permit shall become invalid. I understand that before an Improvements Pecmit can b
issued, I must present a survey plat of the proper[y to the Health Dept. I understand that in the event I have not
delivered a survey plat of the property to the Health Dept. witiiin 60 DAYS afte� the date oE the evaluation of
the site by the Health Dept., this application shall become void and all fecs paid forfcited.
Signe� O�ncr oc Authorized Agent
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So�TN
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+ 0 f�" �' nj i .� G G /fi� �i �S �. � �
Tax Map #:
Zoning
Applica
locatio
PERSON COUNTY ENVIRONMENTAL HEALTH
A�HED PLAN FOR SOiL AREA AiVD SYSTEM LA
Parcel #
Townshin I� �Gc� � �� 1% e��
Subdiviston: �/ U� Secticn: Loi: �
'��proveme�t Permit
� w::ilu�r� aermit �,ann�t be issued with oniv an Improvemertit i-ermit
New ✓ Repair Addition Type of Structure � Water Supply �� ��i�`
# of Occupants __ # of Bedrooms LI Other
Basement? �!' Q._ Basement Fixtures? �
Projected Daily Flow: � g.p.d. Permit Valid For: QFive Years �❑ N Expiration
Proposed Wastewater stem Type: 4 r�,A n/l U2� On
Pump Required? Yes No . �Tnnova6��� ���ucss�ry
Proposed Repair : Pu m0 �- �
Permit Conditions: Koon Son�: �_ /Or� � �rnm WQ Ln S�u
C 10'
Owner or Legal Represen�tive Signatu
Authorized State Agent:
incS
Date: �—� ����
Date: - "l��
The issuance of this perml� by the Health Department in no way guarantees the issuance of other permits. The permit
holder is responsible for checking with appropriate governing 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.
utho
Type of Wastewater System �
Facility Type:
Basement? O Yes No
Wastewater Svstem Requirements
ter System (Required for
Wastewater Flow: y�0 g.p.d.
New �si" Repair OExpansion ❑
Basement Fixtures? 0 Yes O No
Septic Tank Size: 1,� gallons Pump Tank Size: '.� gallons
Total Trench Length: ;� feet Maximum Trench Depth: � inches Aggregate Depth:/a in.
.Akaiamum Soil Cover: � inches Trench Separation: � Feet on Center
Other:_ �e�Ora�l( ��'orr-prOPCr'�/ %ir�CS y�J���F��c�,5e��'tS
Permit Expiration Date: � — �
Authorized State Agent: ' �ate: �" � 3 o?OUO
The type of system permi ed ❑ does ❑ does not differ from the type specified on the application. I accept
the specifications of this permit.
Owner/Legal Representative Signature: _ � Date: Z��'�p �
PCHD, rev. 11/18/99
Application #:
Tax Map #: �I yv
Parcel #: c�,�0
Person County Health Department
Environmental Health Section
SITE SKETCH
�a�o � ��
Applicant's Nam
Authorized State Agent
Da
Subdivision/ ection/Lot#
1-1�--�
Date
��
System components represent approximate contours only. The contractor must Jlag the system
Scale: � /r = ��/
PCHD, rev. 10/12/99
L�ne 1=����
L�wa= �'�1
�i� 3�` f�C°r
L;ne � %�do
�
Person County Health Department
Environmental Health Section
Tax Map #: � ya Parcel #: a9�
Zoning: Township: l�l� %�,� UQi�.
Subdivision: �A l� ' �C%,-24 Section: Lot: ��
Applicant: Gc1�t iC�✓�
Location•
Operation Perm it
��
System Type (In Accordance With Table Va): Co ��- ;�
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
AUTHORIZATION. �D�D ��. ��J�-
..� < �� �- 0�
Auth ized State Agent Date
�
� P�90 qq
,1
'aS° °� o N�e
\ �'�-� g
'�3
Tax Map #:
K
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'�f��� �a� �
(� u-�- �. rn n
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Parcel #:
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PCHD, rev. 10/12/99
Person County Heatth Department
� � ` Environmental Health Section `1
Zoning: Township: �/ 7 �'�l�n.
Subdivision: � ��� Section: Lot: �_
Applicant: I� Q� /� �,✓.�M
Location: l7� i���
Operation Permit
1. LOCATION AND SEPARATION DISTANCES �
A) System meets .1950 setback requirements
B) Distance from system to any welfs
C) Distance from septic tank to foundation ��/ �
D) Distance from system to property lines ih '
2. SEPTIC TANK �
A) Visually inspect the exterior walls and top of the tank
B) Visually inspect the interior walls, baf , tee, filter, riser, lids, air vent,
bottom, and water tight outlet
C) Date of tank manufacture 57P f--S-�D '`�u n''/o �-� �K ���
D) Tank serial number, �p �y� ��"��' ¢�
E) Liquid capacity of tank ���0 gallons ��
�{i G �- P v- MP
3. SUPPLY LINE TO 7RENCHES
A) Grade ��4 (1/8 inch per foot minimum)
B) Material supply line is constructed from .S � � D pl/G
C) Diameter y "
D) Length i�'
E) Distance from tank to drainfield/distribution device
4. DISTRIBUTION DEVICE(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 3(`� inches /
C) Distance between trenches
D) Number of trenches
E) Length(s) oftrenches 1?7' , lSD �. /60� f�p� =�00 %
F) Aggregate depth �[� inches
G) Aggregate material and size j�
H) Record septic tank outlet elevation NA�
I) Trench grade �.a� (< 1/4" per 10')
J) Step downs -T Non�
a. Minimum of 2' of undisturbed earth
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 IVlap #: / ( �� Parcel # � � �
Zonfng Tow�ship �! � �f �� `
Applicant: ���/`ti � ��
. _ „n
Location:
Subdivision: SecUon: Lot: _�._
Well Permit
Tvpe of Water Supplv: ✓ Individual Community Public
Requirements:
Site Approved by � �� �-(�- o �
Grouting Approved by S � (-/1--G�
Well Log ✓�
Well Tag �
Air Vent
Hose Bib
Concrete Slab
Well Driller: �
Well Approved By: •
Date: -" / — � v
**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 anv buildinq foundation.
Other conditions;
PCHD, rev. 11/29/99
PERSON COUNTY ENVIBONMEKTAL HEALTH
WELL LOG
. Date: , - '
Owner.� ��:.rr��l �
Location/Directions:
Subdivision Name:
Drilling Contractor:
w
SR#
Lot #
WELL CONSTRUCt'ION '� -�
Distance from Nearest Properry Line i� Distance from Source of
Pollution �� '
Total Dep.th:_ / L C� Ft. Yield: �p___ GPM Static Water Level
� �� l.
Water Bearing Zones: Depth ��_rt. /_�C�. Ft Ft� �t,
Casing: Dept}i: From_ CS _to J— Ft. Diameter: ��
Inch,.s
TYPE: Steel � Galvanized Steel
. rN, : ���
� �u:r�'
�y'`•'� €•.r
. . _ ; �•
If Steel, does owner app:ov�: Yes No
� Weight: Thicknes :�_ Height Above Ground:�_ jnches
Drive Shoe: Yes �No
Were Problems Encountered in Setting the Casing? Yes No_ _/
If "yes" give reason:
Grout: Type: Neat Sand/Cement � Coricrete
Annular Space Width Inches .
Water in Annular Space: Yes No
_ .. Method: Pumped � - Pressure � � � Poured_ �/�. � � �. .
Depth: From 7� .0 2� Ft. . .
Materials Used: No. Bags Portland Cement Weight of .1 bag__lbs.
If mixtuie (sand, grave ; cuttinos) - Ratio: to
�ID Plates: Yes No � � :. �
�� 4 x 4 slab Yes No �
I HEREBY CERTIFY THAT THE ABOVE INFORMr1TI0N IS CORRECT AND TH AT
THIS WELL WAS CONS3'RUCTED IIV ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERS0�1 C�ui�ITY HEALTH DEPARTMENT.
ignature of Contrac�or Da�c
►..
Type �I (lb) Syste�a d�nspection Checklist
Tax Map �a Parcel # : � �� PIN
Owner: Subdivision: �
• • • - . /�i
• . . ,�L�r�► ��l
1)_ _Establishment_._.. ___.._.. . . . _
a) type, size and sewage flow in
accordance with pernut
2) Tanks
a} tank risers accessible and surface
water diverted
b) tanks and access manholes structurally
sound, watertight
c) sanitary tee(s) in good worldng condition
d) tanks pumped, cleaned out as needed
3) Effluent Dosing Svstem
a) effluent appears clear, free of excess solids
b) required pumps present, operating properly
c) high water alazm present, operating
properly
d) floats, pipes, valves, disconnects in good
working condition, operating properly
e) conirol panel enclosure and components
in good condition, operating properly
fl Drawd'own rate: ^�
4) Ground Asorution Field(sl
a) no evidence of effluent reaching surface
or surface waters
b) surface water being effectively diverted
away from drainfield
c) diversion ditches, swales, tile drains are
well maintained �
d) soil cover, vegetation adequate and
maintained as needed
e) protected from traffic and destructive uses
fl distribution devices in good condition,
worlting properly
g) repair area properly zeserved, maintained
h) pressure head properly adjusted ,..,_
�-, �
YES NO Remarks
_� . [, .
�
��
�
5ummary of Improvements and/or 12epairs Needed:
Authorized Agent
[J
[l
P7-
��
Date