A40 294. . . . .
• - . _
PLEASE SEE ATTACHED PLAN
Tax Map #: ri � l�
Zoning
L AREA AND
Parcel # « { -/
Townsh(p r'0.t �1 � C r
�e��a��5
�,o
T e�n�t � �$
PW��t�
Appllcant: �L/Yl H"�(.Jki nS Znd �ot on�
�o�auo�: jS7S � I-FU-FF2c(. � �i�{,ills �i1G � �Z(:�Gct�"t�'1 �r(�UC
Subdivision:l��Kr��lae- ��"S SecUon: Lot:�
Improvement Permit
A buildinq permit cannot be issued with onlv an Improvement Permit
New � Repair_ Addition _ Type of Structure/i1� Water Supply�ri�a�� �C LL
# of Occupa�ts�p m�X # of Bedrooms 3 Other •
Basement? �c�. Basement Fixtures� .
Projected Daily Flow: �Qg.p.d. Permit Valid For.� Five Years ❑ No Expiration
Proposed Wastewate ystem Type: ��nU ent� ��� � r� s-t�!
Pump Required? Yes No F�� P_t�� �
PermitConditions: .L()�S�l � O(1 C't�/1'�Dl,�r• I�Cep S5l�fCm ���O�F p�opr.r�i I�`/tC�/
J�`o F� �omc lS' c� FF���, c. o F�oad Cu--� .��' S�6�rn �c��l�lu-S F�om �,�e-� ( 90 �% F
poss, b��
Owner or Lega!
Authorized State Agent:
Date:
Date: 0 —J`�"C7C�
The issuance of this permit`by 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 tmprovement Permit shall not be
affected by a change in ownership of the site. This permit is subject to compliance wiih the provislons 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 ��n��� On�l Wastewater Flow: ��g.p.d.
Facility Type: 1���b� IG I� �n'1� New t�' Repair �Expansion ❑�
Basement? 0 Yes o Basement Fixtures? O Yes �'No
Wastewater Svstem Requirements
FJr ��-P�i r
Septic Tank Size: � r� 9allons Pump Tank Size: �O gallons ,
Total Trench Length: ��o feet Maximum Trench Depth: G�O inches Aggregate Depth: loc in.
Maximum Soil Cover: 0 inches Trench Separation: / Feet on Center
otne���i v� i oc�.�r �n -�o� be �L�c�mr`n eal a. Fter SeP�G ! 5� ��5�! I caC �
Permit Expiration Date: � 5 02 � J�
Authorized State Agent: Date: R— 5—oc�
The type of system pe tted ❑ does Q does not differ from the type specified on the application. I accept
the speciflcations of this permit.
Owner/Legal Representative Signature:
Date:
PCHD, rev/ 10/12/99
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PQOIIqt10�1 D�• U � � - � � �-f-E%
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Person Countv Heaith Deaartmerrt
Er�vironmerrtai Heaith 8ectian
Tax Nlaa #: �'• /r��
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, APPUCATtON FOR SERVICFS .
IF THE INFORMAi'ION IN THE APPL1CATtON FOR•AN IMPROVEiIiIENT PERMIT IS FALSIFlEO. CHANGED. OR THE SiTE IS
ALTEiZED THEN'THE IMPROVEiIAEi�11T PERMR AND AUTHORiZAT10N TO CONSTRUCT SHALL BE�OME INVALID.
1) Petmi# roqueated by: (OwnerFaget�prospec�Ive owne�: S � /N /�'1 y ! ��"� �� �NS ,
Home Phone: 3� �� s� �- . qddros� T� SS a��' J r c� � S/�j �C
e�s Pt�one• " '� . C � � s ��'
� Name and addcess of currertt owne�: •.1�A � E
3) Propecly Oescriptton: Lot sizx I Q�Tow� �� ,r
D"�radtons io the propedy pnc3uding road names and rtumbe�s}: �t � i� ���%•
4) Pcaposad Use and Struc:fiu�e Desariptton: anawer eadf af the failowing ques�ons:
� ProPaaed �. Existln9 ❑
b) Sttdc Bw'it q Modular q Singie Wide 4 Double Wide e�
� Number of 8edrooms: � � Number af � o� PeoPie to be se�ved: `f
e) 8aseme� Yas 0. Na.�l ti yes. # of baaert�ent fidurex
�� Garbage Disposa� Yes 4 No.�! ,
gj Dimensionsof Progosed Strv�us: VVidth: �o pepit� ��
� Watec SW�Pht 7jIP@: Ptivaiaki�(t�ew a o� aaisdn9 �. Pu�ie 4 C�u�Y 4�9 �.
Are any w�eds � a�oining proPertY? Y�k1�No 0 lf yes, locx�on
6j Pleaae Indicat� Desi"red Syatiem Type: (syst�s can be ralloed in ocd� of Y�' P���?
vCom�entional IAodified Camsntionai _Aibu�ttve �nnovaiive
Other (spadl�:
CLEARLY STAKE ALL CGRNERS ANO LiNE3 OF THE PROP�RiY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PtPA�SE ATTACti SURVEY PLAT OR S1TE PLAN TO THIS APPUCATiON
I hereby rtiake app8� to the Person Cou�j► t�alth D�actr�erd {oc a a�e evaiu�on 4or the on-aite sewage � sy� �
the above�eesaibed prope�iy. t aqtee that �e cocrt,�ts of this �on ace trus and rep�s�t tho ma�dmum fa�tea to lv
ptacnd on itte p�oQecty. ! undecstand ii the s�e is altered ar the it�ied use ct�angea.lhe pe�mit s1ta� becocne inveQd. l und�n
tl�at as appQcarrt� i am tespor�bie foc id� and mazkin9 P�Y 1�. �ners and matci�tg the s�e � foc th
persanc►el of the Persan CouMy Hea�ith DeQarfinent to cortdud ttu�ir eval�iiona. I ta�d tlrat 1 am t� ��g th
Hea�tt �actrnetrt !f mY��mPerlY� anY wetlands as designaDed bY the AcmY Co�ps ai 6�rs-
,
� c�:-�,� ��.,��..� .� c{ -- ov
oHmer or Le�al Represeatati�e . oaLe
, � i
a
Application #: _
Tax Map #: � ��
Parcel #: :� 9 �
Person County Heaith Department
Environmental Health Section
SITE SKETCH
� :.�Ca.r�n mv� i-i�a�JC► n,� �K�-r d� z(�c��.s � I(�
Applicant's Name Sub ivision/SectionlLot#
�c�� 8 -5 "t�c�
Authorized State Agent Date
Svstem components represent approximate cnntours only. The contractor mustflag the system
scate: � �, SC,
PCHD, rev. 10/1?J99
„.. . � �ers�n Cauniy Heai#h Department
� �virvnmental Health Section a � �
” zaxiNa� �: i� yo a�n� �
Zoning: � Townsiti� ��af /Z r'v� f- � —
Subdivision• G l� ��^c� .P �- S�ction: ,_ Lot /6
��� �OII� in y itr..✓% r'ti.S .
�
Location: a�� � �� �• � . �
� 4 ��ration P�ermit �
-' System Type (tn Acxordance With Tabie Va): � d- � Nu�
THIS SYSTEM HAS BE�id INSTALLED IN COMPLlANCE WITH APPLICABLE N�RTH
CAR�LlNA GE�+IEi�AL STATUTES, RULES FaR SE�IVAGE TREATINENT AND DISPaSAL,
-AND �ALL CONDITIONS OF THE 1MPROVE�AEI�IT PERMIT �AND CONSTRUCTiON
AUTHO N. � �
� `3�.IS�-o(
� Author¢ed Shate � Date
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`'j�ll��
5 6,s �
s�6.f � s �`s, y , 9s�, -
3 (3r•
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PCND, rev. 10M 2J99 .
� .
. r '` person County Hea{th Department
Environmental Health Section /�
Zoning: Township: ��i: �" fCiv'er
Subdivision: ������ � Section: Lot: ��
Applicant• �� rn�y � v'�'� g
Location:. a,� C� �� �'`
Operation Permit
-
1. LOCATION AND SEPARATION DISTANCES
A} System meets .1950 setback requirements E� s
B) Distance from system to any welis 7 �
C) Distance from septic tank to founda6on , S
D) Distance from system to property lines /D rK • h-
2. SEPTIC TANK
A) Visually inspect the exterior walls and top of the tank E'�'
B) Visually inspect the interior walls, baffle, tee, filter, ris r, lids, air vent,
bottom, and water tight outlet e "�
C) Date of tank manufacture - o � .
D) Tank serial number �t(� 20 �
E) Liquid �capacity of tank i000 gallons �
3. SUPPLY L1NE TO TRENCHES
A) Grade ee �✓� (1/8 inch per foot minimum� �
B) Materiai supply li f e is constructed from .S e �ia � y
C) Diameter _�
D) Length j
E) Distance from nk to drainfie distribution device ,�_
4. DISTRIBUTION DEVICE(S)
A) Typa
B) Is Device water tight
C) Distance from the distribution device(s) to the trenches
D) Is the device on a levei foundation
E) E1oes 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 �—inches �
C) Distance between trenches S Oh C�-tr
D) Number of trenches
E) Length(s) of trenches� ./ 3? �!a 8 ��'� �40 3� f°� �
F) Aggregate depth vt inches � S7
G) Aggregate material and size
H) Record septic tank outl t elevation ���
I) Trench grade 42� �����i (< 1/4° per 10')
J) Step downs
a. Minimum of 2' of undisturbed earth ��f
b. Proper rise over step down �e S_
c. Solid pipe used ,
d. Elevations of step owns �► (Record elevations and show on as built)
See "as built" plan on attached sheet.
PCHD, rev. 90/12/99
PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
� �4 � . . a� 4
�ax Map #: Paroel #
Zoning Township ��Q,'� f� l � e�
Applicant: v0.m m v �a" �` � � �
LocaUon•
; /�
Subdivision:
QQ, K� {(� C Gr4i Sectton: Lot:
ype of Water SupplV:
Reauirements•
Site Approved by _
Grouting Ap roved
Well Log �S �
Well Tag�� 3 �
Air Vent '�S 3 ,
Hose Bib �S �
Concrete SIab�S
Well Permit
� Individual Community Pubiic
S 3 'l2 `��
� ��,.�1
. � , +_
;�
. �► , ��
..... ����1;...��►
, ..� -
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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:
it
� �O' �FF pr
`nt� a�' Fr�r�
�n' i�F Dobsib/�.
PCHD, rev. 11/29/99
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date: '
Owner. ��� L�1 � I- � c�
LocationjDirections:
SR# ' � �
Subdivision �Name: _ 1h 1� T��-� Lot #
Drilling Contractor: � � ��
� WELL CONSTRUCTION
Distance from Nearest Properry Line 1 v Distance from Source of
Pollution ( G �
Total.Dep.th: IL Ft. Yield: GPM Static Water Level aS—' Ft.
Water Bearing Zones: Depth 11� Ft. F� Fc. Ft.
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: /�/ Inches
Drive Shoe: Yes ,/ No_ .
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" give r�ason:
Grout: Type: Neat Sand/Cement / Coricrete
A.nnular Space Width � Inches
Water in Aiulular Space: Yes No
_ .. Method: Fumped - Pressure � � Poured � � - � � � �
Dep[h: Fr�m O to a, O Ft.
Ma[erials 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 INFORMr�TION IS CORRECT AND THAT
THIS WELL, WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
�FORTH BY�THE PERSON COui�ITY HEALTH DEPARTMENT.
.. Q�_
Si ature of Contractor at