A40 299Application Date: � ��—� \
Am�ntPaid: 346,OD �6w� ��J
� ReGeipt #: � I I� � I
�� 1
• d'�'�� Person Countv Health Departme�t
� � 6 Environmental Health Section
a- j
�/ �..n 1 . APPLICATION FOR SERVICES
��
TaxMap#: ���
Parcel #: � �
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMiT IS FALSIFIED, CHANGED, OR THE SITE IS
1) Permit requested by: (OwnedagenUprospective owner):�
Home Phone: .33�0 -5�3- �0�7 Address:
Business Phone:
2) Name and address of cuRent owner: �.�� ��r�i,G�vn�
'�
,
��
3) Property Description: �otsize: ��d3 Township:
Directions to the property (Includir}g rQ�,d names and numbers}: I� � r��P �/,
�
��
�j
4) Proposed Use and Structure Description: answer each of the folfowing questions:
a) Proposed�; Existing 0
b) Stick Built �, Modular �, Singte Wde �, Double Wide�
c) Number of Bedrooms: �, d) Number of occupants or people to be served: ��
e) Basement: Yes 0, No�if yes, # of basement fixtures:
� Garbage Disposal: Yes ❑, No,�
g) Dimensions of Proposed SUucture: Width: �� Depth: ��
5) Water Supply Type: Private�'(new,�or existing �), Public a Commun'ity �, Spring �
Are any welis on adjoining property? Yes 0 No � If yes, location
6) Please indicate Desired System Type: (systems can be ranked in order of your preference)
�Conventional _Modified Conventional _ Altemative _, Innovative
Other (specify):
CIEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SRE PLAN TO THIS APPLICATION
1 hereby make application 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
placed on the property. I understand if the site is aitered or the irrte�ded use changes, the permit shall become invalid. i understand
that as applicant, � respo sible for identifying and maricing property lines, comers and making the site accessible for the
personnel of the-Person Co Heaith Depa condud their evaluations. I understand that I am responsible for notifying the
Health Depa,rtriient i� roperty contains��j�d �esignated by the Army Corps of Engineers.
or
z_��..60
Date
PCHD, rev. 10l12/99
<
�
' � PLEAS
Tax Map #:
ACHED
Zoning
Appiicaot: O �. c1, %�
Location: �S%� /� I"�(�Fr �p
Subdivision: �Krl �TRL ���.5 SecUon:
FOR S
Parcel # o! / I
Township r�� c� R i�i G r
LA'
Lot: a L_
Improvement Permit
A buiidina permit cannot be issued with onlv an improvement Permit
New � Repair _ Addition _ Type of Structure�'if} Water Suppiy �n JCtfe W e il
# of Occupan a # of Bedrooms � Other -
Basement? ��—Basement Fixtures��
Projected Daily Flow:��� g.p.d. Permit Valid For: �'fFive Years ❑�lo Expiration
nd Lotc��
Proposed Wastewatef System Type: COn UCfl�i (�f1Cc I C� r0.V ���y �y�,,, ..T�
Pump Required? ,�/ Yes No.� �'F� ySt�m /ID�t � nstcz /rcd��0.S �Ska� �, �''�ay r��u � rc pu.�� n�a��
Permit Conditions: KCZ�,O��C ��� D �F.�D P �4j �[� �D /US �rai►'� �K�S�� �n�
t/
Owner or Legal
Authorized State Agent:
n �i'a
t �tfi�S�6n ��tc. p�'v� tv �`iJSf,� l(a��'o�
Date:
Date: � o?i� � ��
The issuance of this perm� 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 Improvement Permit shall not be
affected by a change in ownership of the site. This permit is subject to compliance with 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 Buildinq Permit)
Type of Wastewater System Ci0/1 V C/1 � � O��i % Wastewater Flow: DD g.p.d.
Facility Type:� 1�� %�D/�'Z L New �Repair DExpansion ❑
Basement? O Yes o Basement Fixtures? O Yes �'I !�O
WastewaterSvstem Requirements �,rF�y,y{tm n�t ins•fa (kc1 aS Stio�ry l,o� 11 I"e�u��C
p u, rnp rcpa i r�i�r'
Septic Tank Size: ,�,� QDO gallons Pump Tank Size: ,�j i�00 gallons
Total Trench Length: '�LN feet Maximum Trench Depth: � inches Aggregate Depth:� in.
Maximum Soil Cover: � inches Trench Separation: -! Feet on Center
other: �nSE,lill IinC,s on coniour� 3'widy -`'i'on �tn�cr
Permit Expiration Date: �02 0 Jo�UIN
Authorized State Agent. Date: J a 0���
The type of system pe itted 0 does Q does not d' r o the type specified on the application. I accept
the specifications of this permit.
Owner/Lega! Representative Signatur • Date: ��
PCHD, rev/ 10/12/99
; . . Application #:
� � Tax Map #• q�
Parcei #: a9`�
Person County Health Department
Environmental Health Section
SITE SKETCH
�'" i�omc MG�x 4aK���d e i�c�eS a I
Applicant' Name Su division/Section/Lot#
3 a�� o�
Authorized State Agent Date
System components represent ap�roximate contours only. The contractor must flag the system
to beginning t{:e installation to insure t1�at proper grade is maintauiea.
�En17�R oF RORO
Scale:
I"" �� ,
PCHD, rev. 10/12/99
0
d
. ' • � Person Goun�ty Health Department
• ' �'� Environmental Health Sectiona�9
• � 3ax Map #: Parcel #•
nin : Township: ���� �' � cr
Zo g
Subdivlsion•OaK�� d� ���LS Section: Lot: a I
.,
,
Applicant: OML ��-K
Location• � F� �a�
O eration Permit
p
System Type (In Accordance With Table Va): .L�
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUT ORIZATION.
, g-I�-��
Authorized State Agent Date
�
.. Q � 5 ����
s�� � a Z
�_� �-pc'�
�, �� �
L;nc Z
�; ,.c 3
�, �.�nc 4
Lsnc �
Tax Map #: t t'1 � Parcel #• �y 7
PCHD, rev. 10/12/99
Person County Health Department
Environmental Health Section
Zoning: Township: �la`� f��Vc�
Subdivision: C�LKr�`dqe i'TCrC,S Section: Lot:�_
Applicant: �Mc P�'�GIK
�ocatjon: �-i�u.F�2�.d
Operation Permit
1. LOCATION AND SEPARATION DISTANCES
A) System meets .1950 setback requirements
B) Distance from system to any weils 1oo'�1us
C) Distance from septic tank to foundation 9`
D) Distance from system to property lines 10'oI�.�S
2. SEPTIC TANK
A) Visually inspect the exterior walis and top of the tank ��
B) Visually inspect the interior walls, ffle, tee, filter, riser, lids, air vent,
bottom, and water tight outlet
C) Date of tank manufacture f^ I 1- 0 O
D) Tank serial number s? �4a
E) Liquid capacity of tank 100 gallons
3. SUPPLY L1NE TO T�CHES
A) Grade (1/8 inch per foot minimum)
B) Material sup�l� line is constructed from �G��� � v �-
C) Diameter �
D) Length �
E) Distance from tank to drainfield/distribution device N�� .
4. DISTRIBUTION DEVICE(S)
A) Type N / /� .
B) Is Device water tight
C) Distance from the distribution device(s) to the trenches
D) Is the device on a level foundation
E) Does the device perform according to its design specifications
F) Record the inlet and outlet elevations
5. NITRIFICATION FIELD
A) Trench depth o�� inches
B) Trench width �v'( —inches i
C) Distance between trenches 9
D) Number of trenches �
E) Length(s) of trenches 'St(a'i g 7 i� 71_� B�i '$ �
F) Aggregate depth � inches, �
G) Aggregate material and size
H) Record septic tank outl elevation
I) T�ench grade � (< 1/4" per 10')
. J) Step downs �
a. Minimum of 2' of undisturbed ea
b. Proper rise over step wn _�
c. Solid pipe used _� �
d. Elevations of step downs '✓ (Record elevations and show on as built)
See "as built" plan on attached sheet.
PCHD, rev. 10/12/99
Application Date:
Amonnt Faid: Z_ •�_
-
R�eCeipr #: i `i 3� ��
�—��
V' � ���� �915
`y� 1� � ���
� ���;
:Laa*Yas-a����azd��_
for 3e�viCes
❑ Improvement Permi� (Site Ev��t�ation} �. t , q�a,�o�,
$200A0/$300.00 if> �00 � d • ' � �+ �`' �� : � = ee is �
� Mob#le ��me Replacementi�br Suilding Additiun .,� 0�ermit
�. $150.00.(if site visit reauiredl _ . '� . ' ��s nn
Permit (New/R.esS�ee
: ,
�l.J�� Taz IVIap: K��
��.� Pa�cel#: q
��.�1��3. �
1�,u�horizatioa
lent on the tvne
'• ❑ Repair of g Septic Syste�m
Application INo Char�e/ CA $150.00 or $30Q.00
1) Applicant Ynfcpr�za9aon: .
Name• � r
•Address• • ' ' '
Z �
�) iVanae and address o� cu�rent o�ner ('ff differ f ihas applicant):
Name• (� � p �
Address: 1�.`"i ,�-4t � rv�n' i�Q
3) I'roperty Descriptioa�: Lot Size: .� (e Subdivisioh:
Address and/or directions to Properiy:
L] yes ❑ no Ltoes the site contain any jurisdicfionaI wetlands?
❑ yes ❑ no Dors the site contain any existing v�3st�wgter systems?.
❑ yes 0 no Is any wastewater going to be generated on.tbe site other tt
0 yes � no Is the site subject to approval by any other public agency?
0 yes ❑ no Are there any easements or right of ways on this property?
(if `yes' is checiced, please provide supporting documentat
4) Proposed Use and'.�ype oiStructure:
�Itesiden#iai '.
O New Single Family Residence Maximwn number ofbedrooms:
� Expansion ofExisting System Ifexpansion: Cu=rentnumber ofbedroo
0 Repair to Malfunctioning System Will there lie a basement? � yes O no
t�I+1on-Residential
Type o€business: Total3quaze fr
Maximum number of employees: Ma�mum nuir
3� W�ter Supply: � New well ❑ Existing Well ❑ Community Well ❑ Pi
Hre there any existing wells, springs, or existing waterlines on this pmperty?
Please note any I�own ground water restrictions or sources of contamination:
� Ii applying %r ��u�horaza�ion io Construci', please �dicate p�e�erred
❑ ConventionaI ❑ Accepted D Innavative ❑ Altemative 0 Otlms=
f
I cert� that the infonnation provided above is complete and correc� I also un
inaqcurat� t�e site is subsequently altet^ec� or the intended use changes, all pe
32gn re (Owner/ Legal Represenrative*)
�` Supporting documentation required.
Q�erEuits a�e v�llid fo� either GO month� or are non-egpiring when
o A complefed `�oi Prepurativn' form mu§t accompany any appIfc
(home): 3310- 322 - 4355 .
C611)• '�J3�,p"�i3"�0?S�n
. ', ,.
Lot �:
�2
domesfic sewage? •
)�
.�
Occupants:
7ith plumbing fixtures? G yes � no
..
tage of Bui.iding. '
er of seats:
�Iic Water (� Spri.ng�.,
7 yes ❑ no
�siem fype(s}:
❑ Any
arstand that if the information pro�ided is
zits altd approvals shall be itrvalid.
� ate '
� -��
omp�nied by an approved pla�
n reqniring a sIte evaluation.
- — — — - - -- - - -- - — - - — -- • -;t — - --- ----- --- - --- ----•
' � � � . , PERSON COUN�Y EIVVIRGNMENTAL_ HEA�TH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Taz Map #: � � `� Parcel # � ��
Zoning Township Fla� 2 ( �%C �
Applicant: ��rn�''.1G"X
LocaUon: I�-FF �oaC�
Subdivfsion: Qaxr� d�f G�C rGS SecUon: Lot: _a1—
Well Permit
Tvpe of Water Suppiv: � Individual Community Public
Requirements•
Site Approved by ✓ �"«"�
Grouting Approved by �/7� � �'" � �"�
Well Log ��� �"��'�
Well Tag
Air Vent
Hose Bib
Concrete Slab
Well Driller: r�� ���
Well Approved By:
Date: �' 3 " ��
**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: Kup Wc I I Yn i n i m �.c. m o�-l5' Frorn
�G
PCHD, rev. 11/29/99
��`i��� � � ����
V� � � ����
IE���������.Il ]HC��fl�
WELL PEN;IVII'�
(New_ Repair �/ ) � L��,�,r�
Tax Map: � Parcel: '• 2`�
Su6division: Da K� c�laQ cr�e� Lot: Gti � Z c.o{ 2(
Applieant's Name: ��, �Q (.�la �Ke Y� se ��1 r lle,,�
Mailing Address: '�
IL��GoTh. r �,
Phone Numbers:
Location of Property:
--� �,-� �-I _ --� ,'
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and Cowzty regulations governing construction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not guarantee a potable water supply
Ot6er Conditions/Comments:
� �
Permit issued by:
QIKTew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Purap Installer:
Approved by:
Additionat Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
R�Yr,�.� Nf �757�
Certif cate of Completion
Depth
Grout:
L�7
Date: _ j2 fY-17
t�7i.iner:
EI�S/Date
. (�Z�
��
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
12-� �-�'�
Phone:336-597-1790 Fax:336-597-7808
„nci,o
-W�:L� CONSTRUCTION REGORD
This form can bc usad for single or mutlipto �vclis
I. �Vet( Contractar,informntion:
`'-'����__��Ci�
�VeII Cnntrdctor Name
y3T�•C
NC Wci! Conhactor Ccrtification N� bcr
f�T�'� lT.,�i�/.�S ,��.
Company Namc
2. Wcil Constructton Permit tt:
LL�•! a!f qppr/Cabje �t�r//Penuits (i.e. Counrr Stale, T'ariance, L fectlnn, ete.J
Welt Usa (checlt well use}:
❑Agricuifuru[ ❑Municipnl/Public
❑Geothermal(Hesting/C�oling Sup}�lyj ��denfiat Wuter Supply {single)
�IndustdallCommercia! qFtesidentiul Woter Supply (shared)
�„_:—.°--
OAquifer Rec6arge
OAquifer Stornge and Recovery
�Aquifcr Tcst
❑Experimentai Technology
OGeothermai (Closed i,00p)
OGroundwater Remediation
OSatinity Barcicr
❑Scormwater Ilydinage
OSubsidence Control
OTracer
4. Dnte Well(s) Completed: !o� /S /'7 ti;�pll IDt�
Sa. bVel! Locutiont •
_ G'FoRG� /f1ju�,Q
Facility/D�vnerNnmu Factli 1Dk(ifapplicable)
.���� a>'dtil.v,�_ o �J .o�c
Piiysuai 4ddass, City, an4 Zip
� �'-.4So.v
L'ounty Parccl ldcntifcation Ro. (P(1�*)
Sb. Latltude and Longitude in degrees/minutes/seconds or decima! degrees:
(iftvell �ie�d, m�e latllm�g is sufficientt
3 �� �"��'i S���N 7� �! � �7 9aY �i
— «�
6. Is (xre) the we!►(sj:� ermanent or ❑Tem{�orury
7. ►s this u repair to nn existing weit: qYcs or C7No •
�f rhLr Lt a�rpu(�; Jil/ o�u !•uiou��t urfl consn•rrction iirfnrnrntfa� mu! erp(aLr 11te uatrrre o j t/�e
�rpnlr u��dc•r l;. /����Qr� s¢ctlon or on �he hcrck ojrlits fonii.
8. Number of wells constructed: �
Fnr �nitfripie !r�/ectioa a• ir�n.u•nter,uippl� ��r!ls p�1'LY iClllt 1J(C SRqIC COqSh'11C!(OJt, �•ai cmi
sr�biult arc/'o�nr.
9. Total �rel! de�th helowlund surPace: __ �p[� �
for irrufd�ife �telLs fist n!1 deprlir ijd(fj'eirnt (eYumple- 3C200' and 1C1 /)0') (�•)
10. Stndc wAter level �
betow top of casing: _ (Tt.)
lf uvfer le�r/ is aGo�Y casiiig. uac �• �,•
I1. Borchole dinmeter: �i �
� (in
12. Wcll construction met�od: G�'�j�y
(i.e. augcr, rotary, cabic, dimcc push, ctc.)
TOR WA7'ER SUPPLY 11'ELLS Oi�'1,y:
1�'�' Y���d ��Pm) -� liethud of test: / r//� P
13b.11isinfecNon ty�c: �r� Amouat: ___ �`� �a`
for Internai Usc ON1,Y: _
a,c. t.er�u�caftott:
�� y.�Ty � ia is i�
Signutu ' c IYc t Contrnclar --�� �— Uatc _��. -•--- -
H,P sr tliir i. / Irereb�� certifi� dmt tlie uL!lts/ ti,•as (irere) cupsn ucted in uccw d�u�re
xTtG l3,q NCAC 02C.0I00 or lJ.d �YCAC 0?C.A?00 {iell Constrt�c�ivrt S�nndards rurd thn( n
copv of lhis rerord ltnr becx prr�vlded to Ilte uY/! nu irer.
23. Site dfngrum or addittonal n�eA deta(ls;
You may use die back of this page to provide additional �ceU site details or we(1
construction details. You t»ay slso attach additional pages if necessary.
SUB�iIT'I'AL PISTUCTIU�S
14�. For Alt Welis: Sub�nit ihis form �vithin 3U dnys of campietion of well
construction to thc fo)iowin�: •
Dlvlsion of IYater Resuurces, lnformntlon ['rocessing Unit,
1 Gl7 Mai! Service Cenier, Rnleigh, NC 27699-i617
24b. Fnr Iniectton Welt� O1Vi.Y; In nddition to sending the form to the address in
2�tu above, also submit a copy of this form �vithin 30 days of completion of weli
construction to tl�c followiny:
Divisfon of �Vnter Resources, Underground InjeoHon Control Progrnm,
1b36 Matl Service Center, Ruleigh, i�C 276g9.163b
24c. For 13'atcr Suppiv & ln(ecNon �Vclis:
�\iso suUmit one copy of this form �vithin 30 daysofcompletionof
�vell wnspvccion to the counry hcalch dcparm�ent of die counry where
constructed.
FOnu G1V-1 Norlh ('uru�ina Deparimant of Envirotunene a�� Natwal Resoumes - p{visfon o£wA�..� n..•......,... -- .
0
Date: � ` �� '� �' '
�wner: �
Location/Directions:
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
„ .. �
.,
�
SR# ' � �
Subdivision Name: Q �d c�s Lot # a(
Drilling Contractor: � Tnc
WELL CONSTRUCTION
Distance from Nearest Property Line 1 v Distance from Source of
Pollution ( G o
Total Dep.th: o�v Ft. Yield: o7s� GPM Static Water Level a.S—' Ft.
Water Bearing Zones: Depth �Ft. Q C� F[. !«� Ft� Ft.
Casing: Depth: From CS to �l7 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 reason: �
Grout: Type: Neat Sand/Cement / Concrete
Annular. Space Width Inches �
. Water in Armular Space: Yes No �
_ .. Method: Pumped � � Pr�ssure � Poured � . _ . . � �
Depth: Fr�m O to �2 � Ft.
Materials Used: No. Bags Portland Cement Weight of .1 ba� lbs.
If mixtuie (sand, gravel; cuttinas) - Ratio: to
ID Plates: Yes � No � � �
� 4 x 4 slab Yes � No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSOv C^vui�'I'Y HEALTH DEPARTMENT.
� � - D-c�J
ignat e of Co c actor Datc