A40 300•ADDIICJtIOfl D�' �l C��G J
Amount P�id: � a, '
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� T�X IIIIaQ #: � �d
Pi1R�� �: � 'o o - .
Person Cou�rtv I�ealth Oeaartmutt
Environmental Heaitl� Sedion
�- � • �• - � �;�� �x
1) Psstni# roquos�ed by: Ownerhgendprospacttw a�rtte�: Sz`J Qn
Homs Pt�on� 3�� 2,f6'�- . q� �
Bt�sineas Pho�e: �� - .
Z� Name and address oi cumerit owner: ��
��
�=96'9 3
3) Propacty Descrlption: �atstz� /�/ Taw�md� ��'P ✓�
D'�rediais ia tlie ProP�Y ��9 road na�nd and nucc�bersX � � Cc0 , .
� PcaQosad Uaa d Stru�ue Descrlption: anawer each cf �tte fa0owin9 Qc�stlona:
a1 Proi�oaed Q�Exle�ng Q
b) Stidc Bu� Q NodWar �. Singie W(de �. �ouble Wide 9�
� Number at Bed�roorns: 3 � Nutnhar oi oca�anis� ac peopts to be secved:
e) Haaerna� Yes Q No I� yea. # of baaement fixturox
• fi Garbsqe Oisposa� Yes 4�� a 8
9i Qh�nsionsot Proposed Strudure: VVkith: �i" � Da�
��r �PPhr �: Privato a�naw � or e�in9 �. P�c 4 4 Spinq �.
Aro a�ry welta on a�o�tinp prope� Yes No � lt ya, bcadon
6j Plws� Indiqb D�ad SYatism TyPe: (syatems can bs raNa�d tn ard� of Y� P�l
vCoaven8o�al i�odifted Conv�atlonal _ Atbmativ� �nt�avative .
Otlw� (sp�iyj:
CLEARLY STAKE ALL CORNERS ANO UNES OF THE PROP�RiY.
STAKE THE CORNER9 OF ALI. P4tOP08ED STRUCTURES.
PLEASE ATi'AC�i SURVEY PU1T OR SiTE PLAN TO THIS APP11C�1T[ON
1 hereby rtiake app6r,atia� bo tf�e Pec�on Camty Heatth D� �6or a a�e av�tion foc ths cn-sibe sawaqe disPo�l sya�n'
tha above�eactibed propesty. 1 agree that the �ta of this ap�ic�lon ace tn� and � the ma�dmtun � ta
pleced on the p�ecty. 1 iu�desstac�d if tha si�s is att�d cr ths � use d�anpea. ihe pom�t shaY bacon�s in+rabd. I t�dorsta
fl�at as ap�ar�t, i am �spor�ie ia id�g and ma�ldn8 P�'oP�Y iinea. co�nesa and �naidng tt�e s�e a�s for t
pecso�nd of the Persat Ccurtty Hea�h Depattrttart to condud their a�val�ctu. l unde�tand i�at l am t� ��9 �
Heaith D if my co�ns any wetlanda aa desi�ns6od bY ��Y C� ��.
�� �'�;�.�.:o $ —��—oo
. o� � R��� . �e
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Ta�c elap �
Zonlnp
Pira11� c� W
Townsmp ��Q�' �t J Ci
�►PP�� �1'"►'1/'n I 1QL.� 1 ✓1-S �
��0,,:15 S� J-�u.�F �2 � i n Ccinc � Autumn Dr-;vc. La� 3rd �n Q
8ubdlvislon:l..c-Vlr(c�f�- / i�--� � SeWon• � ��
Imarovement Permit
A buildin� aermit cannot be issued with oniv an Imarovement Pennit
New�Repair_ Add'fion _ Type of Structure�l,_1�' Water Supply�r��'�G ��i I •
# of Occupants �ir1AyC• # of Bedrooms ,y� Other _____._ •
Basemant? �,_ Baseme�t Fi�ires? �1� .
Projeded Daily Flow:�� g.p.d. Permit Valid For. �Fve Years ❑ No Expiration
Proposed Wsstewater�Systerri T pe: 1 �0 R1X-i �`'� 0(Lrl. ���QUJ 1�
Pump Required? Yes,�No .
Pe��tcona-�o�: =�5-�af( 5�.��5-f�m d� COntou..�� �Ou..S� IOca-��on
. n
c�n �
Owner or Legal
Authorized State Agen�
oate• - /� � v
Tha issuance of this pertnitipy the Nealth Departmerrt in no way guarantees the issuance of other permits. The pem►it
holder is responsible for checking with appropriate goveming bodies in mseting their requirements. This � site is
aubjeat to �evocation if tha site plan� plat, or the intended use changes. The Improvement Permit shail not be
affected by a change in ownership of the slbe. This permit is subject to compliance with the provisions of the
Laws and Rules for Sewage Treatment and Dtsposa� 3!►�tams of the North Carolina Administrative Code.
Authorization To Construct Wastewater Svstem (Reauired for Buildtn� Permit)
Type of Wastawater System �'�1UUi� D�G. ( Wastewater F1ow: s�.p.d. -
Fadiity Type: mob � ��- I' Dm { . New �" RepalrOExpanslon ❑
Basement? 0 Yes �.No Basemerrt F'u�ures? C� Yes �1'jdo
Wastewater Svstem Reaulremerrts
Septic Tank Size: I, D0� gallons Pump Tank Sfze: N� %� gaUons
Total Trench Length: `T� feet Maximum Trench Depth: � inches Aggregate Depth: �oi in.
�° '_c.,sS t�'' � c� �
'NtSxlmaRt Soii over. � inches Trench Se on: Feet on CeMer .
Other.
�n�5�( ( e h�n d�.c, -� r x� n. ��. a F a��r�`.�n.-t
Pertnit Expiretion Date: O� � �S�P ��G S y�S �E�S
Authorized State Agent: Date: i �`r�� �
The type of system perm d❑ does 0 nct differ f m th type specified on the applicatfon: I accept
the specifications of this permit �
OwnedLegal Representative 8tgnature: � � L` Da� , � / � � O �
PCHD, rev! 10/12/99
.�
. � � . �
Application #:
Tax Map #: f�9�
Parcel #: 3oa
Person County Health Department
Environmental Health Section � '
SITE SKETCH
��irl M y�ac�K i n5 Ou Kn cr �?
�9 C. � 4S —
Applicant's Name Su ivision/Section/Lot#
��� �l.% l 4� ��
Authorized State Agent Date
System compnnents represent approximate cnntours only. The contractor must flag the system
Scale:
Ij'-�/
PCHD, rev. 10/�12/99
. � Petson C�unty Hesith Depariment . .
Envirnnmental Heslth Sectlon. • . �
Tax Map �: +�� Pan:et �: �?� Q
Zoning: � Township: �1,�,� f�r���
8ubdivbdon: � �i d� � 8edton: _ l-� _S�'1.Y •
Applia�ri� �G1�C ` Cf�D
Lott�iYdon: � � � Cl �'r /t G'�--� � /7u � m� .D/' � de, �3 ,,., _ �j
�T�
a e�ration ��.Permit �
� System Type (In Acxo�clance With Table Ve): —�
�
T�ilg SYSTEM HAS BEEN INSTALLED IN COMPUANCE WITH APPLICABLE NORTH
CAROLlNA �3ENERAL STATUTE9, RULES FOR SEWAQE TREATNENT AND DISP08AL;
.AND ALL CONDITION3 �F TME IMPROVEMENT PERAIIT AND CONSTRUCTION
AUTHORIZ,ATION.
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S �
�tno st�e a��t o�e
r o�'
911�:,
.;
1/7
�ap r . .
�D a �
l o � = y�° �
��s -/000
sT� /�� �
7—a/-6 0
PCHD, rev.1Q/12199
♦ • �
Person County Heafth Department
Environmental Health Section �,� ,f
Zoning: Township: � � / � �rv�
Subdivision: Section: Lot: � �
Applicant: S'a vn m�rAllC,n �
Location• 0`rJ� ` %��� %J/� Lo 7� �r��-- �
.� � �
o13G'i'�$10� �el"Il'11��
1. LOCATlON AND SEPARATION DISTANCES �
A) System meets .1950 setback requirements ��_
B) Distance from system to any welis �D6 �
C) Distance from septic tankto foundation S r
D) Distance from system to property lines !o �
2. SERTIC TANK
A) Visually inspect the exterior walls and top of the tank
B) Visually inspect the interior walls, baffle, tee, filter, riser, ds, air vent,
bottom, and water tight outlet ��
C) Date of tank manufacture �,— a/-o 0
D) Tank serial number �7(3 �'!2
E) Liquid capacity of tank l000 gallons
3. SUPPLY LINE TO TRENCHES
A) Grade (1J8 inch per foot minimum
B) Material supply line is constructed from � P U�
C) Diameter '7� .,
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
Iv 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 q
A) Trench depth 1 v inches �
B) Trench width �inches /�► /
� C) Distance between trenches � t'oD 1- �� �
D) Number of trenches S
E) Length(s) of trenches �n' 91' Il7 ` I�0 � lD a�
F) Aggregate depth �_ inches ,r.�
G) Aggregate material and size tt �%
H) Record septic tank out et elevation -�'_5 `/�I
I) Trench grade (< 1!4" per 10')
J) Step downs
a._ Minimum of 2' of undisturbed e�rth � 1s� S��O �n 3���i
b. Proper rise over step down `P\I 1) `� j
c. Solid pipe used � �
d. Elevations of step downs (Record elevations and show on as built)
See "as built" plam m� attached sheet.
,A
PCHD, rev. 10/12/99
PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR �iNELL`SITE LAYOUT
Tax Map #:
��O Parcell� ���
ZoNng Township �I a'� � '"� V �
ApplicanC
�m�V %{�-�KL nS
LocaUon: ��� ! G 1�-1 ' � �T
�
Subdivislon:
r� G �e.l�� Section: Lo� �__
Well Permit
Tvpe of Water Suppiv
. \/ Individuai Community Public
Reauirements•
ed b � �� �r �- (o-�
Site Approv y
Grouting Approve .by �K I%as.r/�
Well Log
Well Tag ,� �� Z `'�
Air Vent � c� 2 ob
Hose Bib �� S r` 2°o
Concrete Slab " 2 �6
Well Driller• � r�- �e
Weli Approved By: , -
,
Date: �� Z a�
**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 conditio
PCHD, rev. 11/29/99
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date:iG-a��-oo �
Owner. � � %1Y � S-� � SR#
Location/Duections:
Subdivision Name:
Drilling Contractor:
�
Lot # a�
WELL CONSTRUC'I'ION �
Distance from Nearest Properry Line J v Distance from Source of
Pollution ( G �
Total Dep.th: Ft. Yield: GPM Static Water Level a..� Ft.
Water Bearing Zones: Depth �_Ft. 3G� F� Ft� Ft.
Casing: Depth: From 6 to�Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel
If Steel, does owner approve: Y�s No
� Weigh[: 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 / Concrete
Annular. Space Width Inches �
Water in Annular Space: Yes No
_ .. Method: Pumped - Pressure � � Poured � . _ - - �
Depth: Fr�m O :o �2 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 INFORM�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSOV COTs�TY HEALTH DEPARTMENT.
�.' :: /�:��� �. .� r R r i
���-_
► ' • • • �
�
Application Date• y"�'' �7
Amount Paid: i�. 00
Receipt #: ! � 3�' 1 �
��
•.-��� ) f ��ll�l� `U�l � Taz Map:1y � u _
._,.. .► • � Parcel#: �Q�_
. ��- �. � �7��r�p�n
:L=�.'.Il1Y7'1�Q3II�Ilh3t3.21�.i3Il llllK�QY�::[3
�#! � 5 Application for Services
5ervices Re uested
❑ Improvement Permit (Site Evglµation) � ti4 � . C�: Construct,�n Authorization
$Z00.00/$300.00 i�> 600 d ���'+ `�-'- ee is de endent on the e
❑ Mobile Home Replacemen�kbr Building Addition ., O Permit Revision
. $150.00.lif site visit reauiredl . - '' � . � $7.5.00 _ __ _
Permit
❑ Repair of
1) Applicant Infqrmation: , '•
Name• � ^
�Address: � '
2) Name and address of current owner (if different than applicant):
Name: : �Pc,t �„�.�' �4��,�t .
Address: /y,��,�-�t�'�.nn �r'
�,mT�—Q �, �,'�7� �
3) Property Description: Lot Size: Subdivisiob:
Addres,s and/or directions to Pr�erty: ,�
N
Septic System
azee/ CA $150.00 or $300.00
Phone (home): 33� 322 �- ��LL-
(work/cell):
r� �
Phone:
Lot #:
� � y�s ❑ no I�oes the site con�ain any jurisdictional wetlandsT ' - '
❑ yes ❑ no Does the site contain any existing w�st�water systems?.
� yes ❑ no Is any wastewater going to be generatedtin.the site other than domesric sewage? ���,� ���.
❑ yes 0 no Is the site subject to approval by any other public agency?
❑ yes ❑ no Are there any easements or right of ways on this property? �
(if `yes' is checked, please provide supporting documentation) �
. � ' • - ��"�%
4) Proposed Use and Type of Structure: " �, j ��
❑Residential '� V�
❑ New Single Family Residence Maximum number of bedrooms: / Occupants:
❑ Expansion of Existing System If expansion: Cuirent number of bedrooms: •
❑ Repair to Malfunctioning System Will there be a basement? !7 yes ❑ no With plumbing fixtures? ❑ yes � no
❑Non-Residential
Type of business: Total Square footage of Building:
Maximum number of employees: Ma�unum number of seats:
,
5) Water Supply: 0 New well [t�xisting Well ❑ Community Well � Public Water ❑ Spring''�
Are there any exisring wells, springs, or existing waterlines on this properiy? 0 yes � no
Please note any laiown ground water reslrictions or sources of contamination:
� If applying for `Authorization to Construct', please i�dicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative O Alternative ❑ Othet --.�,,� ❑ Any
: .-_ _ - .
I cert� that the information provided above is
inaccurate, the si� subsequently al�red„�r/�
'� Supporting documentation required.
nplete and correct. I also understand that if the information provided is
intended use chgnges, all permits and approvals shall be invalid.
� _ � "� y =,�? -
Date
• Permits are valid for either 60 months or are non-ezpiring when accomp�nied by an approved plat.
• A compieted `Lot Preparation' form must accompany any application requiring a site evaluation.
���.sf ���.����
�- � � ����
]E ��,� � �,� m,� �.Il IE 7L � 8 fl �lEa
WELL PERMI�T
(New_ Repair ✓ )
Tax Map: � Parcel: 3 ob
Subdivision: daKr� �r. creS
Applicant's Name: v 1J�i��f' F�{��o.
Mailing Address: ���,�„�„ (k'.
�d ��. � %s'�Y
PhoneNumbers: 3�(a�583-G,��lr ol.►, Q�{ovti� _
Lot: �_
Location of Property: �-(ti,�% �, -_7 � �� � � (� � =7 %�n �Yu wtn
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulatio�ts governing construction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does no guarantee a potable water supply
Other Conditious/Comments: �o,�v,� � fn i n S� l� I/n P i
Perrait issued by:
Qlvew Well: .
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Additional Com`nents:
Date Sample Collected:
EHS:
Person County Environmentai Heaith
325 5, Morgan St.,Suite C
Rnvl+nm �I!' �7G7�
Date: �1- 5 - � 7
Certificate of Completion
�iner:
EHS/Date
Depth: �—��� s
Grout: ��-�—� -�5- (
�
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336•597-7808
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