A40 293, ►
u
A��Iication Date; �'�6��6 po
Amount Paid: �d 6 �3 �J�. �
Receipt #: 66
��� ( D� � Person County Heaith Department
Environmental Health Sectlon
, APPLICATION FOR SERVICES
—' .. : :'Services Requested . :.:
P ft R orded Loq • 515� oo � Wel1 Pertnit (NewlReplacen
Improvements ertn ( ec ,
❑ Improvements Permit - (Unrecorded Lot) -
❑ Impravements Pertnit-5100.U0
(Mobile Hqme ReplacemenUAddition)
�. .......�,.,,�,.,,, e„�ti�,;,�r���. c�nn no
1) Permit requested by: (OwnerlagenUprospective owner):_
Home Phone: �-p� Address:
Business Phone: �g� / �
2) Name and addres� of current owner:
Existing System Inspection - S
0
Existing
Site Plan -
T� M� #• � ��
Parcel #: � � �
. 5125.00
3) Property Description: Lot size; � Township: ��gL.�L,(!/��- �
Directions to the prope u ing road names d numbers): �
. � �
4) Proposed Use and Structure Description: answer each of the foliowing questions:
a) Proposed�Existing ❑
b) Stick B It 0, Modular 0, ingle Wide 0, Double Wide
c) Number of Bedrooms: d) Num er ot occupants or people to be served:
e) Basement: Ye:s 0, No t�f yes, # c>f basement fixtures:
� Garbage Disposal: Yes 0, No
g) Dimensions of Proposed 5t cture: Widtho� Depth: �
5) Water Supply Type: Private new C7 or existing �), Public 0, Community �, Spring ❑ �
Are any welis on adjoining property? Yes 0'�� If yes, location .
t 6) Piease Indicate Desired System Type: (systems can be ranked in order of your preference)
�Conventional��Modified Conventional _ Altemative Innovative
Other (specify): _
�
CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPER7Y.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SI7E PLAN TO TNIS APPLICA710N
I hereby make appiication to the Person County Health Department for a site evaluation for the on-site sewage disposal system for
the above-described property. I agree that the contents of this application are true and represent the maximum facilities to be
place n th property. I understand if the site (s altered or the intended use changes, the permR shall become invalid. I understand
t as ap icant, I��m responsible for identifying and marking property lines, comers and making the site accessibie for the
personne f e Person County Health Department to conduct their evalualions. 1 understand that I am responsible for notifying the
Health rtment if my property t s ny wetl ds a signated by the Army Corps oi Engineers.
6- l 6-o d
� O er or Legal Repre:�entative Date
� PCHD, rev. 10l12/99
� � ■ I � C � LOT
�1 � a i �� ,�O 5 ' "OAK RIDGt�E A�
� PHAS! ONE
� N �-+ "OAK � ACRES" � P.C. 11, P. °
� � LO �I�I Z PH E NE
� � "OAK RIDG ACRES" '�� t �" P.C. 1, P. 57-F � �
\ L07 7 1 PNAS E �' (n � '
� "OAKPHASEEONERES" 1 P.C. 11, P: 57-F � I! I I r � '
�� P.C. 11, P. 57-F j / � i i i� �
i \ 1 t i I�rn . � N07'27'4A"N
" 187 . 69'
� N05'55'43 w
� � � 43"W NF� 5.00'�-��T ��TAL IF
I "OAK RIDGEBACRES" \� IF N05'S LtOT jOTAL IF U�+ IF 22T � �
� PHASE ONE � � 32„W 225 . 00' � o $ i�� �� N
� P.C. 11, P. 57-F p3 � i � d c �, N ,� 6
\ N� 6� 2 2 r' x =�' � �-� � �' � 0�
I � 8� • cn I : c`'; ; 2� .` .P o
� , IF N 12 I� -�' -+-� 16 g� ACRE
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CONTROL .�, 9 • S�S�c?� � r � � L_c7� � j��_ �- - - NS
CORNER � � �, , ,_ _ � L� 25.oa' NS '
IF � Q �' � • IS ___-- -_ �- NS S05'S5' 43"E 2s.00' 81 _83=�
, � `sr,,�� ,- S05'55�43��E _ 225.00__---
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DRAINAGE 3o.s2' �
i IS • EASE�AENT �% `i I r
13
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�� oo NS 81 .51' i� , ACRES ��cO,, � S06'05� 70,TAt IS
�. � �. �0 y �� /� I IS 225.00
Z ACRE IS-� �v v IS N S83' 34' 51 °E 16�
NS 40. � •5
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� `,y0 o,�Q-`' ��o�Rry � �P�, i g i �� I S S05
\ �^ � .hh� �1 �0�� � I I
� h� �`� �h^ ^ W I TNESS '`� '� .
\ /1 ry�,� / �,�"�� ,�:� IRON SET a6� ���: �
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IS 96.72' � IS h,
SOS'21'46"W IS / /� � � �
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PLEASE SEE ATTACHED PLAN
7ax Map #: 1 1 —1 �
Zoning _
Applicant:
LocaUon:.
L IY10. X
FF Rd
Subdivision: �Kr�a4G / 1�-rCS SecUon:
AND SYSTEM
Pa�e�# a�3
Township �IQf F(U�-�
� n.'s
La� L Gt� i�ttc�5�c,-�1on W/ I/����c.ce n
Lot: �S
Improvement Permit
A buildinq permit cannot be issued with oniv an Improvement Permit
New,�,/Repair_ Addition _ Type of Structure(11� Water Supply nrti �u-�- W�� �
r�
# of Occupants � # of Bedrooms 3 Other •
Basement? j�Q, Basement Fixtures.�
Projected Daily FIow:3�Qg.p.d. Permit Valid For. �Five Years ❑ No Expiration
Proposed Wastewater ystem Type: �� n V e(l'��' o ncc, � G r�i v �'C1�
Pump Required? �Yes No� Fo r�c pu � r
Permit Conditions:�(,�1-►1t S�i°►'i J�rl S P� � F� �d Qr�'-�` � /`��P—�Ys�-m �s �F��m
,�J4� o�F R.cx�.d cu.�, �a' a FF p�op�r /inyS, S�oFF kom�, '8�'From w� � i
Owner or Legal
Authorized State Agent:
Date:
Date: � � ��
The issuance of this permitwy the Health Department in no way guarantees fhe issuance of other permits. The peRnit
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 wiEh 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 Buildina Permit)
Type of Wastewater System C',anvenfi ana I Wastewater Flow: �c l7 .p.d.
Facility Type: � �C. NOM e
Basement? 0 Yes [�i o
Wastewater Svstem Reauirements
Septic Tank Size: 00� gallons
New �Repair DExpansion O
Basement Fixtures? O Yes �
p � ���C�(p6i i r)
Pum Tank Size: _f� ga7lons
Total Trench Length: �� feet Maximum Trench Depth: �4 inches Aggregate Depth� in.
Maximum Soil Cover: �a inches Trench Separation: -/ Feet on Center
Other: �/1��� � Q f'i CD(1 �b(,l!—,
Permit Expiration Date: �—S o ��S
Authorized State Agent: • Date: o—� ��
The type of system perm ed ❑ does Q does not iff ro the type specified on the app ication. I accept
the specifications of this pertnit. /
Owner/Legal f2epresentative Signature• �a�� � U
PCHD, rev/ 10/12/99
� � .
� � . Applfcation #:
• Tax Map #: ,A-4, O !.
Parcel #• �q �
Person County Heaith Department
Environmental Health Section
SITE SKETCH
.�
��Mel�Yl�i-x �a.Kr��dSe 14crc.s J`�
Applicant's Name Su division/Section/Lot#
_ ' �-S ��
Authorized State Agent Date �
System components represent approximate cnntours only. The contractor must flag the system
ntior to be�innin� the installatinn to insure that proper grade is maintained
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Scale:
PCHD, rev. 10/12/99
. ' -"� ' Person County Heaith Department
n Enviranmental Health Section
Tax Map #: #1' �D , Parcel #. � � 3
p�
Zoning: Township: ���� i��J��
Subdivision: �_ ��'c�Cle• ��S Section: Lo� l �
Applicar� �in2l��
Location: 157� � F�i ��� QLtS�I vi S�h.
4peration Permit
. _ ��
System Type (In Acxordance With Table Va): �
THIS SYSTEM HAS BEEN INSTALLED IN COMPUANCE WITH APPLlCABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITiONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZATION. �
O �
uthorized Sta ent Date
PCHD, rev. 10/12/99
Person County Health Department
Environmental Health Section�A � �,��
Zoning: Township: �/G�
Subdlvision: Section• Lot: �
Applicant: �����
Location• �s7 s � `ru?� !�' � D����S �``
Operation Permit
1. LOCATION AND SEPARATION DISTANCES
A) System meets .195Q setback requirements L� s
B) Distance from system to any welis o�" �
C) Distance from septic tank to foundation
D) Distance from system to property lines If1 ��� -
2. SEPTIC TANK
A) Visually inspect the exterior wails and top of the tank �
B) Visually inspect the interior walis, baffle, tee, fiiter, riser, lids, air vent,
bottom, and water tight outlet �
C) Date of tank manufacture a. 3 o a
D) Tank serial number STB ��
E) Liquid capacity of fank lc�a galions
3. SUPPLY LINE TO TRENCHES
A) Grade S�' %h (1/8 inch per foot mirn um�)
B) Material supply I� is constructed from 4� 5�o P�'�
C) Diameter 3
D) Length S �-/
E) Distance from tank to ainfi distribution device
4. DISTRIBUTION DEVICE(S)
A) Type /��
� B) Is Device water tight �_
C) Distance from the distribution device(s) to the trenches /V�
D) Is the device on a levei foundation N�-
E) Does the device perForm according to its design specifications �
F) Record the inlet and outlet elevations �/f�
5. NITRIFICATION FIELD
A) Trench depth inches
B) Trench width __._�__ inches /'
C) Distance between trenches ��h �'��
D) Number of trencNes � , i � � �
E) Length(s) of trenches ,�n ��F /'i f 36 f6�7 f�3 �7 / f�'� T�30
F) Aggregate depth ,�a inches � ,r„�
G) Aggregate material and size �
H) Record septic tank outl t elevation � 3
I) Trench grade SC'e �rJi (< 1/4" per 10')
J) Step downs �
� a. Minimum of 2' of undisturbed ea�rt�
b. Proper rise over step down �' ._
c. Solid pipe used �
d. Elevations of step downs �P�� / ecord elevations and show on as built)
See "as built" plan on attached sheet.
PCHD, rev. 10/12/99
j
/
/
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date: �'ao '
Owner. �%s�►
Location/Directions:
��
Subdivision Name: c��k ;-c .� Lot # S�
Drilling Contractor: � � ►�c
� WELI. CONSTRUC'I'ION
Distance from Nearest Property Line � v Distance from Source of
Pollution t G a
Total.Dep.th: ��ll� Ft. Yield: C� PM Static Water Level �Z.S� Ft.
Water Bearing Zones: Depth —����' �7 [. F[. F[.
Casing: Depth: From 6 to�_Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel
If Steel, does owner approve: Y�s No
� � Weight: Thickness:� '� Height�Above Ground: I�/ Inches
Drive Shoe: Yes ✓ No .
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" give r�ason:
Grout: Type: Neat SandJCement / Coricrete
Annular. Space Width � Inches �
Water in Arinular Space: Yes No
. _ Method: Pumped - Pressure � Poured � - - �
Depth: Fr�m O to � C� 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 INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY-THE PERSON COui�ITY HEALTH DEPARTMENT.
Signaturc of Contractor D�tc
�..
� .
Tax Map #: � � � Parcel fF � � �
2oning
7ownship � �a"t �" � � Cr
Appiicant: � " �m C ��" X �
LocaUon•
� r
Subdivislon:
(� Kr � C� G e- ��l� Section: Lot /-
Well Permit
T e of Water Su i: �ndividual Community Public
Reauirements•
Site Approved by ��tJ �
Grouting Approved by �/ 3 u�1
Well Log ✓ a �
Well Tag
Air Vent
Hose Bib �-
Concrete Slab
. - � -� :��
�►.�j, >
• • . . - . ��I' � � .:_' 1
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:
'n I��S � u-� � F I� i tG�
��FF
i �
Ke�eP �D � F'�o m SePt�c � F Possi bIc .
5v' F�am
f �-S 5 � own ,
PCHD, rev. 11/29/99