A40 296e►cclkatlo� oam: g—/6' °"
Amount Pdd: �a� �P�.
B�-.
s
. Tax Mao #: � `��
�� �9�
- • L IL1 r�.l!l �.l•� C11 :ll
S► 1:� Llitll.-, �_ r�� ... .�
' 'a�_���l��i.��� i %�a/ h�
i� � hQ1i�� ..7•�(�1MR�t�g� �Y�!
� Han� Phonx 3 6� a-,�G � .
8toiness Phone: "
Z� Nam� and addtess ot curceat own�: SA- �'%
3i �P�ll �oe� Lot six� � 0 9 Taw�l� �/Q,
Oi�ecttons tc the prop�rty pncluc�t� tnad nac�w And twmbecak
� Ptapos�d Ua� attd Sbr�ctuc� D�scrlptlao: answet �ch af ths foBawinp que�ocm:
�
�,� 3
� �4��q0
b} Sddc 8wlt 4 lloduiar 4�q�s !N6de 0. Da�bls Wids9�
d Nwnbsc of Bedroamx �-- � N�uc�r d ocapants ar p�opl� m be sscve� `�
e) BasemenC Yes q No.�f tf yea. � ot ba;anent �tu�ex�, ., ,..
'� �acbaQe o�a� Yes 4 Na.�
� Qi�n�ionsot Proposed Str�s: WidttL � Dep�tr 6'0
�1 ��PP�Y �s Private�i�e�w 0 0� �odaWep �I. F�lie 4 Coan�Y 4 Sp�CW �.
An any w�s an adjoir�inp p�opat�t Yes9'�lo G It y�s, bcafio�
bj PMts� indica� D�sie+�d Sysiam ZYP�: (syatems can be rania�d !n o� af Y� P�'�l
�Coav«t�lonal Modtfi�d C�anv�lo�al _AN�c�w �av�w .
Otlw �:
CLEARLY 9TAKE /LLL tt�RRNEFtg ANC LINES OF THE PROP9tTY.
STAKE THE CORNERS OF /1LL. P�OPOSED STRUC'iU[iEB.
�ase arr� suRVFr Pu►T oRsrrE �.�wTo tws a�►noN
���lf R� aPP� to tt�e Pa�aon Ccunty Health D��afit�ant%r s a� avak�atlon �or ttw cn-siis aaw�p� disPo:al ayst�m '
ttw abovadesc�ib�d qopecty. l aQces that the co�ents of t�is appYc�ion ac� frus and c�ep�ant the tcaodmtm f�ltas to
Pta�c�d on ihe pnoQecty. 1 tmde�and �ihe a�s is ai�eoed artt� indrded tw d'�. tt� perttt�� bscocns invalid. � tridec�ta
tlmt as ap� I atn �po�e fac idenWjRq and nmrici� P�P«hl �. �caas and maiti�p the si�e a�le iot t
Pecaonnd of Pes�on Cau�ty Heaitl�► Oep�trne�t bo conduct their avak�lions.l u�a�ac�d th�t 1 am taapona�b ��9 .
FieaYh If rt�y propacty w�tlands a� d�d bY tt� AmiY Ccxps af Eipi�sa�a,
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Receipt' 0 2��
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�� 7��� IO-3G-60
APP�,ICATION F(l t SrRVI �
-�..._
1/Improvements Permit(EstablishedlRcco"rdcd Lot) I_ Reinspection oF Existing Syscem (L,oan Closin�)
Improvemenls Permi( Nnrecorded Lot)
_ lmprovements Permit (Mobile Home Replace)
Improvements Permit (Addition)
_ 2epair/Replace existing Sepcic System
_ Permit for New Well
_ Replace Existing Well
1. Permit requested by: .{�.�„�Q��{ �, �?�r� 7. Dimensions or Proposed Scructure: �
owner/prospective owner/agent: �ow�E►+a�q-,c ��,�; Width: _�g
Address: _ _. 35ni r',�,� �'d., " Depth: r76
�
.�..�. __ .. -
w
�" Home Phone #t:
a,
usiness Phone �:�33 So�_r�,.,g.�
W
�
z
2: � I�Iame and address of current owner:
3. Property Description: L,ot size:
8. What type (if any, additions, expansions, or
replacement is anticipated to the stn�cture or facilicy
that this sewage disposal system is intended to serve?
�Vater su ly t}'pe:
%< < privacei�. p�ublic ❑ community ❑ spring ❑
-� s?� Are any wells on adjoining property?Yes ❑ No [�
If so, identify location:
Tax Map#:_�. �tj �� ig�
Parcel#: �Z.R3 �'9L
Township: �(�,�: �; s,n �,-
Directions to property: S ate Road #& Road
mes,�t .�� sot � f��'f-DN F(a T�
. c�,►�G. ,2�► x f�f�d[� wt:lls �Pd.
,t�r I-�,., _,�'.c l�.J i' �.. � - - - — - - • - � • •
� wVN Ie't" 6�J'r'CJH : L.J�
`�
I�Iumber of occupants or people co be se�rred: ,.�
I0. Type of stnictureJfacility: Proposed: �Exiscing: Q�'
Type af dwelling:
House: ❑ Mobile Home: Lh'Business: ❑
Type of business:
I�Iumber of Employees: �
Number of bedrooms: _ c{- �
Garbage Disposal? Yes � No �
Basement? Yes❑ Noi�'�so, # of basement fixtures:
CLEARL"Y STAKE ALL CORNERS pg TT3E pROPERTY AND TIiE CORNERS OR ALL
PROPOSED S`Z'RUCZ'URES.
: hereby make application to the Pet'sOri COUI1fy �ealth Dep3i'tmeilt for a site evaluation for the on-sice
sewage disposa! system for the above described propercy. I agree that the contenes of this application are true
and represent the maximum facilities to be placed on the property. I understand if the site is altered or the
intended use cfianges, the permit shall become invalid. I understand that before an Improvements PeRni[ can b�
issued, I must present a survey plat of the properey (o che Healch Dept. I understand that in the event I have not
delivered a survey plal of the property �o�the Health Dept. wi�bin 60 DAYS after the dace of the evaluation of
che si[e by the f-iealch Dept., this application shall become void and all fees paid forfeited.
ncr or Authorizcd Agcnt
�
0
9
G
n
..� �. �� ...�1 � : �� �.
,....�.----..,.�._..
�� ►.:�
� � va
v�c �� S
0
1
�- �
T��� Pr4o �� �`��
Zoning __Township F�0.'� �I VCr
wPPlicant:
Locatlon•
�C
s�,��won: QaKri dqc A���S s.aio�: -- t.,� 1�
��� (,�-� Znd o� Q
Im�rovement Permit
A building pennit cannot be issued with onlv an imarovement Permft
New � Repair _ Add'�ion _ Type of Structure �1 � Water Supply Dri Vc�tc- W ��� �
/� r
# of Occupants � �x # of Bedrooms —f Other _ • .
Basemenl? �Q_ Basement Fb�ires? � •
Prajeded Daily Flow: � g.p.d. Permit Val(d For. � Five Years 0 No F�cpiration
Propased Wastewate yster►i Type:� U �t�a Jl ��1 ��n U c/) �,l Q� �� rci v i�/
Pump Required? �Yes No Fo ��pQ,,r ._
Permit Condi�ons: �n 4Ea l l 5 rrn C�S Stio r.�n ,�YS �r''► �a5 bccn F/a�i9cd ar�
�
Owner or Legai
Autho�ized State Agen�
�i�5
Date:
Date: � - �
The issuance of thls pecmi[ bY the Health Departmerrt in no way guarantees the issusnce of other pem�its. The pertnit
holder is responsible for checking with approPriale 9oveming bodies In mes6ng their requirements. This � aite is
aubJect to revocation if tl�e site plan� plat, orlhe intended use changes. The Improvement Permit shall not be
affeated by a change in ownership of the site. Thts permit is subject to compliance with the provtsioas of the
Laws and Rules for Seuvage Treatment and Disposai 3ysbems of tfie North Carolina Administrative Code.
Authorization To Construct Wastewater Svstem (ReQuired for Buildtn� Permit)
Type of Wastewater System�vurfional �r�t✓r�y Wastewater Flow:�ig,_ O a.p.d. �
Fadiity Type: ' G oM� . New� RepafrOExpanslon ❑
Basement? 0 Yes � o Basement Fixtures? 0 Yes�B(No
�,IVastewater Svstem Reaulremerrts
Fo� P.c�� r
Septic Tank Size:1� 000 9allons Pump Tank Size: � ga���$
Total Trench Length:J��� feat Maximum T�ench Dapth:�.Q_ �nches Aggregate Depth:� in.
m�i-h�qmQm Soii Cover. 0 inches Trench Sepa�ation: �, Feet on Carrtec _
•
ther. C� � = E �P T��• ��.E �" r`
PeRnit E�iration Oate: ` a — O �
Authorized State Agent: Date: as"" �
The type of system pe tted O does D does not dlffer from the e specified on tha application: 1 accept
the speciflcatlona of this permit '
OwneNLega) Rapresentative Stgnature� -r- �ebe: i/�S/o0
PCHD, rev/ 10/12/99
�
i
' Application #:
Tax Map #: U
Parcel #: �9(0
Person County Health Departrnent
Environmental Health Section
SITE SKETCH
* `�on � Pt �rce ,t�1-xKr� ��� �c�c.5 � � _
Applican 's Name S divisioNSection/Lot#
� � `���5 a�
Authorized State Agent Date
System components represent approzimate contours only. ?'he contractor mustJlag the system
nrior to be�innin� the installation to insure that proper graJe is maintainer�
i0' � 1��� _ 10� �r� 10' y
f . {Lc.Q�� � � pp b�i �S, . ` `
e�MQ o-�,�i ` ��5� � ao� R tio
10 I ' n�� �°�\ ��'��` �
�} qi.��c,�,c �`� � A1` -, .
�� � F 1 � o�' ,,w , �
. ��� `�0
I 1�
-� I — — � , ' —1, vs, .
5 , �! 5 F, �� 1
3�' � va� �
f �
+�r=`J.O�
Scale:
� 5y5�c�n ha5 bzcn F�a55�
on 5 itc, =nvta t t a5
Fl�y��
rivz
PCHD, rev. '! 0!'I?J99
.
, . . Person County Heaith Departrnent . .
Environmental Health Section � . .
Tax Map #: � y� Parael #:
Zoning: Tovmahlp: F! �`i�� �
Subdivisic
Appticari�
Locatlon:
�ton: 1-�� ��
CJ, l� D� �� /Z ����� Dr�,'�c�
. LB �- � o� 2��
� eration �Perm it
.�
System Type (In Acxordance With Tabie Va): ���
TH1S SYSTEM HAS BEEN INSTALLED IN C�MPLIANCE WITH APPUCABLE NORTH
CAROLlNA GENERAL STATUTES, RULES FaR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDtT10NS OF THE 1MPRt)VEMENT PERMIT AND CONSTRUCTION
AUTHOR1ZATlON.
� l o� o0
orized State Agent Date
. �
. ���GU/`_
0
aoX� a
4
�
�S `
PCHD, rev. 10/12l99
,
Person County Hea{#h Department
Environmental Health Section�.�� �. J�
Zoning: Township: r
Subdiviston: rTG�f,/�, Section:
Applicant: (�n✓i �i e�,��
Location� 5 � �w�-�.— --�
� � ��-� uw�r� br� � a �✓� ��� ,
Operatoora Permit
• 1� LOCATlON AND SEPARATION DISTANCES
A) System meets .1950 setback requiremen�s
B) Distance from system to any welis � �" f,`//�
C) Distance frorn septic tank to foundation 7'
D) Distance from system to property lines r o'
Lot: �_
2. SEPTIC TANK
A) Visually inspect the exterior walls and top of the tank
B) VisuaAy inspect the interior wails, baffle, tee, filter, riser, ids, air vent,
bottom, and water tight outlet� -�_
C) Date of tank manufacture �R 10 0
D) Tank serial number 5�/� iNa
E) Liquid capacity of tank (ooD gallons
3. SUPPLY LINE TO TRENCHES
A) Grade (1/8 inch per foot minimum)
B) Material supply line is constructed from
C) Diameter
a
D) Length
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 foundati�n
E) Does the device pertorm according to its design specifications
F) Record the inlet and outlet elevations
r�h �j
— 5 y
-� �n�/�
5. NITRIFICATION FIELD -
A) Trench depth c� inches �
B) Trench width �_ inches y
� C) Distance between trenches ('o � "I
D) Number of trenches '7 , � , �
E) Length(s) of trenches I yG' �oy ' 1��� �' 6a .S� (oo =, S9�
F) Aggrega#e depth �_ inches
G) Aggregate materiai and size ��`
H) Record septic tank outle elevation s' �''
I) Trench grade .� r (< 1/4" per 10')
J) Step downs
a. Minimum of 2' of undisturbed earth �
b. Proper rise over step down � s,� �fa� ��—� �5� �u �'''�
c. Solid pipe used �
d. Elevations of step owns (Record elevations and show on as built)
See "�s built" plan on attached sheet.
-
� ,�
S s�
�p
PCHD, rev. 10/12/99
PERSON COUNTY Ei�IUIRONMENTAL HEALTH
�•� PLEASE SEE ATTACHED PLA►N FOR WELL SITE LAYOUT
Tax Map #: � � O Parcal !F ,
ZoNng Township �iQ� � � v �'F
Applican�
�omc, (�'lr�x �`�
�,�,�a�. �c %�e�m i t
� /�
Subdivlsiom �a
r � d G �Cr ��ection: Lo4
Well Permit
Tvae of Water Supaiv: �ndividual Community Public
Reauirements-
.�,.�' �4 /3 � o �
Site Approved by �
Grouting Approved by�
Well Log � C�
Well Tag �' � l o � 09
Air Vent �' �° � � °
Hose Bib � �- `�s �` @0
Concrete Slab� ro �O `s°
.. �
Well Driller:
Well Appro�
Date: �� � � °�°'
**See Attached Site Sketch**
Wells must be 10 feet from property lines.
Welis must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions: �rl,���l I(�e-� � C�5 �5hbt�n on Srte.- SKct�
PCHD, rev. 11/29/99
' ' . PERSON COUNTY ENVIRONMENTAL HEALTH
�.. WELL LOG �
Date: - d •�
Owner �e�c� C ��K�t
Location/Directions: �
SR# ' � �
Subdivision �Name: O� C �s Lot # l
Drilling Contractor:^ � Tnc
'z . WELL CONSTRUCTTON
Distance from Nearest Property Line 1 v Distance from Source of
�Pollution ( G a
Total.Dep.th: � D Ft. Yield: GPM Static Water Level a.3—' Ft. x.
Water Bearing Zones: Depth �' d F[. /�C� F� 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� Above Ground: /�/ Inches
Drive Shoe: Yes ✓ No �
i
Were Froblems Encountered in Setting the Casing? Yes No � �
If "yes" gi� e r�ason:
Grout: Type: Neat SandjCement / Coricrete '
Annular. Space Width � Inches �
Water in Armular Space: Yes No
_ -. Method: Pumped - Pressure � Poured � . _ . . � -
Depth: From O to �, O Ft. �
Materials Used: No. Bags Portland Cement Weight of .1 ba�_lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes � No � � �
� 4 x 4 slab Yes i No �
� DRILLING LOG �
I HEREBY CERTIFY THAT THE AB�VE INFORMr�TION IS CORRECT AND THAT
T�S WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C�uiJTY HEALTH DEPARTMENT.