A40 291.. AQoqatlon Oata: l='p o
Pmount P�id_Q�} �
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Tax Nl�o �k � T A
Pa�eel �: 2 %/
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IF THE INFORMATION IN THE APPUCATION FOR �AN IMPROVEII�ENT P�RMIT 13 FALSIR�. C�WNGED OR THE S17E IS
ALT'EitED, THEN'THE 1MPROVEiYIEidT PERMR AND AUTHORiZAT10N 1'� CONSTRUCT SHALL BEC�ME lNVAL1D
1) P*rntit roqwatied h: (Ovmsdag�ntlprospadivo owns�: �5��1 iY! %��,�1 �i k/�J S
• liomePhon� �Y Z,f"C2 � A�d�sx �f�f �Rp�" %iGe r,,�lJ,
Busirtiesa Phane: " � x .pu �,�. c. � 2 9 S 7�
Zj Nam. and addrsss of curnscrt oyvne�
SA r� t
3) Pf+OQ�r1y D�sCtipt�0e: Lotsts� �� �`� Tawnt,t� =.1_ � o tF /� D.
D�aWo��a ta the p�opedY (Irx�+din9 t�d t�emea �rtd rusmbe�sX
4) PtoQos�d Us� d 3tsucitttr Descriptioe: answet esdt ef the fdbwicW que�ons:
a1 �roPosed �� a
b� snac awlc a, Modutsr e, sic�ple wfde Double vwde e�
c� Number ot eedroom� .,:��.�� �,e. 5"� � Number ot oca,panb. a� p�ia to be saNac� �
a) 8aeemec�C Yea Q No 0"It yes. �+of basert��t fixtitu�
• fi Garbage Dtsposa� Yes Q No �
� Qi�nansionsof Ptv�wsed S�a VVdtt�: �$ pappttr Co
���PPh► 'TYP� F'rtvats 0'(new a or aodadna a�. Pubic q C«nn�t�► a. spfiw a.
Ars any weqa an a�oi�ig popal�? Yes�No � tf yes, location
6j PMas� Indicab Daii�d Sysiom TYP�: (sya�ma pn bs r�do■d In o�t ot Y� P�l
�Ccnvatttlonat Modifled Coav�ntior�al _ Aib�t �o�va
Ott� (sQrdtyj:
CLEARLY 3TAKE ALL CORl�IER3 ANO 11NES OF THE PROP�ATY.
STAKE THE CORNEi�S OF ALL PROPO8ED STRUCTURES.
PLEASE ATTACiI SURVEY PU1T OR S1TE PI.AN TO 'iii{3 APPUCA'1'ION
I t�eraby make apQB� Do the Pe�on Camty Fkalth Dapartmmd ibc a a�e ev�fuation tor the an-si0s sawaqe dbP�al sYat�m
tha abave�esa�bed proQeily. t aqree that tha cot�t,ecth of this appllcat{o� �ce trus and tep�aac�t 1he ma�atuun iac�itl�as bo
ptacad on the proQecty. ! ur�do�tand if the sim is altecnd a�@ts ��ier�ded uss dtac�s. ttte pemt� sha�Y bemme irnrd(d. t wtders�
ttt�t as app�nt, I am tespons�e fa ida�ing and ma�iun4 WnP�Y �, �me� and maldng the si�e aa� Ea�c
peesonnd af the Petson Caurty Hea�h D�artrneat bo conduct tt�ir avakmileris. I ia�ecstand ihat I am t� �"�9
Health D tf my c�ns any we4tanda as dai�bed blf ��m1f C� ��rs-
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. N * WATER COURSES 11�Y BE SUBJECT Tt
� � °i • I DIVISION BUFFERS. CONTqCT THE
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WITNESS J LAND DISTURBINGE�CT�IVITIESBCOMA
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Tax Map i�: ��0 Parcel # a/ � Township F'A �� I V Q1� PIN
AppUcartt 7tlnnr� T�r�1��nS Subdiviston �IKYiAqC �tG`(�PS Phase/3e�tion � !offi �� -
l.ocatlon: --- - - h1t�t.�� F-��`�l '
' Imt�rovement P�rmit
New � Addition Type of Stnicture 3�• KL�s �� Q�� �Y Water Supply �'I
# of Occupants # of Bedrooms 3
Projected Daily �iow. 3(e0 g.p.d. Pi
Proposed Wastewater System: h�e.
Proposed Repair. onve,�
Other
t.
System Type� � •
or. Five Years ❑ No Exniration
Permit Conditions: �eA SVsfiev►• i5� .�,,.,� ��Ou,i Id,.� .�cu.,�,�'�v. cu�.� IS�;�o,� � a`,�c� c,Q; �,s�u,,
r . ,. -. - . - . — � ,. � � —•—�-
Owner or Legal Representative
Authorized State Agent:
oate: 6 � `� '�O 1
Date: � ' 2 ' � �
The issuance of this permit by the Health Departmen�"in no way guarantees the issuance of other pertnits. The pertnit holder is
responsible for checking with appropdate goveming bodies in meeGng their requirements. This site is subject to r+evocation if
the site plan, plat, or tha intended use changes. The Improvement Permit shall not 6e affected by a change in ownership
af the site. This permit is subject to compliance with the provisions of the Laws and Rules for Sewage Tr+eatment and
Disposal Systems of the North Carolina Administrative Code.
, Authorization To Construct Wastewater Svstem 1Reauired for Buildina Permitl
WastewaterSystem Description: ��efii a-� Wastewater Flow: 3 G o a,p.d.� Type:-�—�. •
Facility Description: ��' �� S C`1 «*X NewJ� � Repafr �] Expansion O
Basement? ❑ Yes No Basement �bctures? � Yes No
Wastewater Svstem Reauirements
Tankage: Septic Tank size 00 gal. Pump Tank size l�% f�— gal. Grease Trap size /U�- gal.
Trenches: "fotal length Q � ft. Trench �dth 3 ft. Total Area a�0 sq. ft.
Max. Trench Depth: � in. Aggregate Depth:� in. Soil Cover. _� in. Trench Separation �ft. on center
Permit Expiration Date: c:�'
Authorized State Agent Date:� � ��
*See attached site plan and addendum pages f dditional permit conditions. ,
The type of system pennitted ❑ does ❑ ot differ from the type specif+ed on the application. 1 accept the
specftications of this permit �
OwnedLega! Represerrtative Signature: Date: �'"� j
Opera n Permit
System Type (in accordance with Table Va) _ �
This system has been installed in compliance with appltcable ido�th Caroli� t3eneral StaWtes, Laws and Rules for Sewage Treatrnent
and Disposal, and alt conditions of the Improvemer►t Permit and Construction Auihoraation. Issuance of this pertnit implies no
guara�ee that ihe sysbem installed will functlon prope�fy for any given period of time.
Authorized State Agent Date
PCHD, rev. 03/07101
P�rs�n ��ty �eaitla. Depar�aetrt
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�L�SE S� ���C�3E�? P!�&V F�R �iL �iTE �YOU'i'
Tinc 9Yp�1t
r7- �%� wa.+� � / / .
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� Tune of �JVater S�oi�t: .
�
• iNe11 P9inlit ' .
� Comrrtuniiy . Pt�biic
Rsauir+etnan�s: _
Site APproved bY . .
Groufaig Approved bS/. �
Wel1 L.og - .
� VYefl Tag • ' .
A� Vent � .
t�ase e� - �
Concr�e S�ab .
�
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— ,� ` ' . ' ry'Y�``�
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� -� C� J C� ,�,v,-e/�. ° .s.f�'� .
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. Well Driiier: � . .
' Well Approved By: �' �
i"'See k�cl�ed Stts Simtch" �
.= We11s niust b� 10 feetfrom p�l �-
� VV�s must� be 100 fieet from se�Ic sys�r�s- .
WeUs must be at l�st 25 f�t fra[n anY bw�din9 foundation.
Othe.� condiiior�.s: � .
� G�.� 1:7�• �� �� �� .
. S�lo � �� �;��. t�,�� V�� .
� . ��
�� . � .
PCii�, re+r. 1Z/Z9� .
„ ,�,e�niic�ation !]ate: � �°?6 --� �
.�,mou.��# �aid•
�teasipt #:
- �prson Cauniv Health Department
r . _ ,�,;�nvironr¢;sntal Health Section
� ' ''::, APPLICATION FOR SERVICES
T�tt Maa #t: /�� a
Parczl #• � � (
�-� f. 3 �;�
oak ._:,
. �� � :.:.
IF THE INFORMATION IN THE APPUCATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED, CHANGED. OR THE SITE IS
ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME 1NVALlD.
1) Permlt requesbed by: (Ownerlage�rtlpraspective owne�: � °�� � e-� �- � �--� (
Home Phone: � Address:
Business Phone: �
2) Name and address oi current owner. �
3) Property Description: Lot size: Townshlp:
Directions to the property (Including road names and numbers): �
�-� � � kl r, r., P � .D��„M i�
4) Proposed Use and Structure Description: answer each of the foflowing questions: �
a) Proposed�Existing ❑ �
b) Sfldc Bui(t ��1lrlodular �. Single Wide �, Double Wide ❑ �
c) Number of Bedrooms: � d) Number of occupants or peopie to be served:
e). .Basement . Yes �, No ❑ If yes. # of basement fndures: . . . . � . . . . . .. . . . ` .-
-�- -
.
� � Garta,aae,Disp�al: Yes �� ,�a �...<.. . . ._....�:., .. _.., . , .... .. ... . . . . ,.. . .: . ...._�.. .._.._ . � . .... ._ .... .
g) Dimensions of Proposed Strudure: Width: Depth: �
5) Water Supply Type: Private,�9.(new � or existtng �), Public �, Community ❑, Spring ❑
. � Are any welis on adjoining propert}�T Yes ❑ No � If yes, location
6) Please Indicate Desired System Type: (systems can be ranked in order of your prefeience)
Conventional �Modifled Conventional _ Altemative. Innovative
Other (specify): �
CLEARLY STAKE ALL CORNERS AND LINE3 OF Ti�iE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPL1CATiON
I hereby make applicatian to the Person County Heaith Department for a site evaluation for the on-site sewage disposal system for
the above-described property. I ag�ee that the contents of this application are true and represent'the ma�dmum facil'�1es to be
placed on the property. I understand if the site is aitered or the intended use changes, the permit shall become invalid. I understand
that as appiiprrt, I am responsible for identifying and marking property lines, comers and making the site accessible for the
personnei of the Person Courrty Health Department to condud their evaluatians. I understand that I am responsible for notiiying the
Health Department if my p%pe�ontains any wetlands as designated by the Army Carps of Engineers.
�
� ” ��d�
Date �
PCHD, rev. 10l12l99
,
• ' . ..
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V J
Application #:
Tax Map #: �
Parcel #:
��n �� Person County Health Departrnent
� � 11� Environmenta! Health Sect�on
Y ��
SITE �SKETCH
� �c i k� �.� n c-�`tc. � �Kr i d� c Crc,,s
Appiicant's Name S�J divisiaNSection/Lot#
- Co ac�-�i
Authorized State Agent Date �
Svstem components represent approximate contours only. The contractor mustflag the system
tn beginning the installation to insure that proper grade is maintainer�
Scale:
. nc,�, Wc.0 �•„-
PCHD, rev. 10/�12199
Person County Health Department
/��[ Environmental Health Section
Tax Map #: /1 7� Parcei #:
Zoning: Township: I U ��-
Su6division: � l\ P►� G� Section: __L-- Lot: �
Applicant• �� � �� •
Location•
4peration Permi�
System Type (In Accordance �th Table Va): —o�
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WlTH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES �OR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITiONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTiON
AUTHORIZATION.
�
.�
Authorized State Agent
i
�� �
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Tax Map #:
� ���i �o
� Date
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y'��� ���_�
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6� „ �y<< /
Parcel #-
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PCHD, rev. 10/12/99
PERSON COUNTY ENVIRONMENTAL HEALTH
' PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
� �4a Pa�,� � � �
Tax Map #:
Zonlog
Township �I �.� � I V C. r
Applicant I` L� v' 1 r`"'"�n �'��
Locatlon:
S LoG �
Subdivisiom rl1 � t- C([ S�on•
Weli Permit
Tv�
e of Water Su I: V Individual Community Public
Reauirements•
Site Approved by r%3 �4 to a5-o
Grouting Approved by �' � � a�"'��
Well Log � K- � � - o
Well Tag - -o
Air Vent ✓ � -o�
Hose Bib � �- (
Concrete Slab � � I
. �� � 1 �
. . . - . �_!_:����� �� . .:a
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
Date: � �� � � U � '
Owner._ ��
Location/Directions:
� � .` o� G��
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG � �
. � � � _ Q
' SR#� .� .,� -� .
. _ , . . ✓�... , i i i , r � ., i► _
Subdivision Name: I' 'o .� _� Lot # I 3
Drilling Contractor: � � ��
WELI. CONSTRUC'I'ION
Distance from Nearest Property Line ! v Distance from Source of
Pollution l G a
Total.Dep.th: /J� F� Yield: O GPM Static Water Level a.S" F�
Water Bearing Zones: Depth �'D Ft.���'��Ft Ft� F[.
Casing: Depth: From 6 to�Ft. Diameter: Inches `
TYPE: Steel - Galvanized Steel
If Steel, does owner approve: Y�s No
� � Weight: � Thickness:�. '� Height�Atiove Ground: /�i Inches
Drive Shoe: Yes ✓ No .
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 Aimular Space: Yes No
_ .. Method: Pumped - Pr�ssure � Poured � - � � � -
Depth: Fr�m O to �2 � 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 i No
I HEREBY CERTIFY THAT THE ABOVE TNFORMr�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTT REGULATIONS SET
FORTH BY�THE PERSON C�`vi1TY HEALTH ]�EPART,NbE�.
S �nafure of CorEractor
� -��
Dac�
m
. � � .
• W��� �,�� � n
b� �' � (�'� s
a' ��t' PERSON COUNTY ENVIRONMENTAL HEALTH
�L � ���t�"�a-J'�, WELL LOG �
� �. . : . ll/ �. -�'D Li, � ` � U c�
. � u. c nu.� �
Date: _ � '
Owner.
Location/Directions: —
Subdivision Name:
Drilling Contractor:
Go� G��`�`"P�` to -o t
, ��., �-a
.,
�
��
Lot #
WELL CONSTRUCTION V
Distance from Nearest Properry Line 1 c1 Distance from Source of
Pollution t G o
Total.Dep.th: /2U FG Yield: � GPM Static Water Level a.S'' Ft.
Water Bearing Zones: Depth �. Ft. � Ft� F� �t.
Casing: Depth: From 6 to��,Ft. Diameter: Inches
TYPE: Steel - Galvanized Steel
If S teel, does owner approve: Y�s No
� � WeighG � Thickness:� '� HeightAbove Ground: /�/ Inches
Drive Shoe: Yes �/ No .
Were Problems Encountered in Setting the Casing? Yes No �
, If "yes" give r�ason:
G.rout: Type: Neat Sand/Cemen[ / Coricre[e
Annular Space Width � Inches �
Water in Annular Space: Yes � No
_ -. Me.thod: Pumped � - Pr�ssure � Poureci � � - � � . .
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
� DRILLING LOG �
I HEREBY CERTIFY THAT THE ABOVE 1NFORM�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C�ui1TY HEALTH DEPART .
. (o -1 hD,
Sig ature of C ractor Dacc