A40 2950
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Tax Mao #: �" � °
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Pacr.sl #: � 9 �
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eu�ess Pho�e: �
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3j PtoPutY Os�tlPtlax t.otai� /, 0'7 Ta�r�pC � /
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DYactions La the prop�tty p�� toad tmmes artd txuabentx �J -� �
4) P�pos�d Us� and S�ucttn D�scdptlan: �nswet �ach af ths �p Rue�ona:
a} P�oPaad 4 E�nq 0
b) Stldc Buit 0. tulodutar 4 Si��pis Wlde 0. Da�ble Wide�A�
� Numbec at Bedroomx _3 � N� d oceupants ar peo� bo be san+a� �,
e) Bassc�nt Yes q No 8'if yea. # of ba:ematit 16�ucec ..{:�,
' f� Garb�e � Yes q No t�
� �at �ro� scn�e: v�: �oep� ��
�1 ��PP�Y � Ptivate�-(�taMr Q oc �odaWw �q. Pu�c 4 Co�xa�r o. sp�na 0.
An arry w�Ms on adjoinip propett�t Yes 0 No �ItyM, iocation
6j PMas� Inaik� Daii+�d SYstwn 'iYp�: (sys�ass can b� ra�do�d !n oN�r of Y� P�'�l
�/Coav�lonal I�Md Conv�atbnai _ A� �twva�lw �
Othr �Q�[yj:
-t CLEARLY STAKE ALL CORliEiig AND LWES OF THE PROP�RTY.
' STAKE THE CGRNEi�S OF I1L1. P�OP08ED STR11C'fUiiEB.
Pl.EA3E ATTA�i SU[tVEY PU1T OR SiTE PI.AN TO'TH{S APP�1CATiON
1 he�'ebY maks � to the Paaon Caady Health O�pe�na�t ior a s�s ivak�atlon ior tt� on-dbs aewap� ��'
ttN abovadesp��d propaly. l aqros tt�at tha ca�tentd of thb appl�t{on an trw and t��t the mtoortw�n ta�es ta
placad on the pcopuly. I�u�d�aatand 7the a�s is al�ecnd ath� ��dad tw ct�p�. ttw pertt�tstw� becans irnr4Yd.1 tmdecats
t�t as �pp�nk. 1�mm c+espon�i� io� id�aNiiyirq aad rtw�lonq P�opeclY licr�s, �xs and �aaidrq tlts a�s aa�e bt t
perso�nai af 1he Pes�on Caurty HeaNh �trn� bo conduci it�eir wduatloc�s. l u�atactid ihat 1 am t+eapon�s ia' �iY�9 .
He�th � mY P�P�I �Y �s � desi�d hY tt� AcmY Cacps af 6pibacs.
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�pal R�prwataltve . Oabe
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Tax Nap �
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ZoNng --TownsWp /— �CLt l�.1 VC r
�PP��� s�Q�11iY11! l�aL�%(I�r1,s
��n: ���7�5 � l-�u FF /�d ,� Du,S�� n Lane. � fFc�tum� D�i �c 3�� l o� D��
��Y�.�: �1a Kr� dti�.,� c�cs s.�o�• ,.� i�
New � Repair _ Addi�on _ Type of Siructure m� Water Supply �t'i Ja �e W��� � .
# of Occupants �1A,X• # of Bedrooms � Other •
Basement? �8asement Fixhires? �Q •
Projeded Daily Fiow: � g•p.d. Permit Valid For. j�( Fve Years ❑ No Expiration
Proposed Wastewa_ t�'Systetn Type: � Can ven-���c�n Q% 1�r0. V�`�
Pump Required? V Yes No Fo r�Pai �
PermitCond'�tions: ��,Sta-(t S v�5-�cm a�5 Fkt-y�cd on l� by E�`-l�S� ����5 l-���11
. _ .r, . . / �i _ i �-, � _ . ,,.,.��.,
Owner o� Legal
Autho�ized State Agen�
Date: �' 3 `Q �'—
Date: �
The issuence af this perrn� by the Fiealih �ePartmerrt in no way gua�rantees the Issuanca of other permits. The pertnit
hoider is responsibis for d�ecking with appropriate goveming bodies in meeting their requirements. Thts � site is
subject to revocation if the site plan� plat, or the Intended uee chan8es. The Improvement Permit shall not be
affectsd by a changa in ownership of the siffi. This perm[t ls subject to compliance with the provislons of the
Laws and Rules for 8ewage Treatment and Disposal Systems of tfie North Carolina Administrativa Code.
Authorization To Construct Wastewater Svstem (Required for Building Permit)
Type of Wastewater System �D�V�n�lbn� -�-�'�-�%;��tewater Flow; 3�O(�a.p.d. •
FadtityType:�Ylo6ilc Nom� . N�►�t Repa(�OExpanslon❑
Basemeni? 0 Yes {�I,No Basement Fixtures? 0 Yes �No
yvastewatersvstem Reaulremsrrts �� (�Pa,;r
Sep�c Tank Size: 1, �D gallons Pump Tank Size: �'� 9�lons
Total Trench Length: � feet Maximum Trench Dapth: � inches Aggregate Depth:� In.
minimun �
Maxl�rti Soii Cover. � inches Trench Separation: � Feet on CeMer .
ocner�if ��cr mu� be, loc�fed on �'�tc Driof't0 v��c �`n6�1(a,-��on
Pertnit E�iration Date: '� � o�a �
Authorized State Agent: Date: � i 0-�
The type of system perm d O does � does ot dJffer from the type specified on the application: 1 accept
the specifications of this pertnit -
Owner/Legai RepresentaUve Signature: �� Date: q�3 �� �
PCHD, rev/ 10/12/99
�
Application #:
Tax Map #: O
Parcel #• .�95
Person County Heaith Departrnent
Environmentai Health Section
SITE SKETCH
� �.mm F�Q�Ki S �r�d z �+�rc,s J-7
A plicant's Name S division/Section/Lot#
_ ' 9=/� - oa
Authorized State Agent Date
System components represent approximate contours only. The contractor mustJlag the system
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Scale: �
PCHD, rev. 10/12l99
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� Ti�.9 eYS7�1 �UI�S BEH�! W9TA11.Es� IW COlSPlJAt� YYIt'H APPLk:ABI.E NOR'fH
�� � CAROLlNA CiEN�tAL STAT1nES� RUL.EB FOR SBNAGE 'iREAT1ENT AND �
�' .J11� ALL t�ON.9 OF 7HE IYPROV��IT P9i1Bt • MID CONSTRUCf tON
� ALlitl�A�ION- .
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stais ApeaEt : � �
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PERSON COUNTY ENVIRONMENTAL HEALTH
' . PLEASE SEE ATTACHED P".:AN FOR WELL SITE LAYOU i�
Ta�c AAaP #: ��� Parcel iF �f ! �
Zoning Township ! /Q� 1���Cr
m f -�ac.��nS
AppUcan� � Y -
Location• J�- e- t iiYl l't
; ��
Subdivision•
Qa.Kri dqc. (�cr�SS�o�: ���
Tvue of Water Suppiv:
Re4uirements•
Well Permit
� individual Community Public
Site Approved by
Grouting Ap oved by ' `'�~°�
Weil Log
Welf 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: .-� n�ta I I (.J e-1 I a.5 S�•oc�n �n S� � v�kctc,�i 1.
Wclf � ' � �
PCHD, rev. 11/29/99
��� Sf ���.��� ��a�� 230
` ' �— � � �T �T'IC`' �Y" c�� a� .� I �nrt�J� �C
��.��-��-�.��¢�.�. ���.n�� � D�o Dr��(1o�1 5'Z2 -oZ
�(�mm �' 1d �� � i NS Well Log 0
Owner: Tax Map ��'i, Parcel # Z.Q 5
Locarion: �
Subdivision: — Lot # �_
Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from Se tic System (Minimum 60 feet)
Total Depth: 1�.2.ft Yield: �� GPM Static Water Level: ft
Water Bearing Zones: Depth _� ft ft ft ft
Casing:
1
Depth: From � to �3 ft. Diameter: �p �4 in
Type: Galvanized Steel ✓
Weight: Thickness: . I gg Height above Ground: in
Drive Shoe: TYes No Any problems encountered while setti.ng casing? Yes No
If `�es" give reason:
Grout:
Neat: Sand/Cement ✓ Concrete GraveUCement
Annular Space Width � Z. inches Water in Annular Space Yes No
Method of Grout: Pumped Pressure Poured ✓ Depth � to �� Ft.
Materials Used:
No. Bags Portland cement Weight of 1 Bag Pounds
If mixture (sand, gravel, cuttings) — Ratio to
ID plates: ✓ Yes _ No 4 x 4 slab ✓ Yes — No
Drilli.ng Log Location Drawing
From To Formation ���
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I ZZ C!� �� �w�. )5.� s
1141
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I hereby certify that the above information is correct and that this well was constructed in accordance with regulations
set forth by the Person Coun Health Departme t.
Signature of Contractor ID # � � Date �'"z3' �Z
PC�ID rev 01 / 16/02