A40 302•.'Aanlication Date: � °Z9`�d
' Amount Paid: 3' ���
Receipt #: �
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:
Tax Map #• � �O,
Parcel #: 3 0 2�
Person CountY Heaith Department
Environmental Heaith Section
, APPLICATION FOR SERVICES �
1) Permit requested by: (Owner/agentlprospective owner): j�j�� /U Li X
Home Phone: Address: �3�Q ( ��.
Business Phone: s'331� ti���-�'�$`7 ���h�� /`
2) Name and address of current owner. ��� n,t����j{ Ul�,� n� .,_
;,1 ProFerry Description: �ot sze: �� l� T�ship: �-� llr� �^� .�
Directions to th� property (including rpad names anc n�,mbers): _ r-YC!v1__ �;
( j f,L� [�'o-T-Uc �nrci 1� L1 � t 1 S� �i c l �tG� C�1��-'1�"'� ��-1
�!� '%-;�9- �gh�-. 'I aKs- f=-►�5+ �.. h�' La�f- w� 1� on� � I.e�-.
4) Proposed Use �nd Structure Descn�tion: answer eaG� of e following Guesti�r� ;:
a) Proposed �,. Existing ❑ - : .
b) Stick Built C:, Modul�r �, �ingle Wide 0 Oouble Wid� �
cl Number o` Bedrooms: � d) Number of oc�.up�nts o* people to be s�rven
e) Basement: Yes �, No �If yes, af ba��ent fixtures:�
f; Garoage Disposal: Yes i�? No 0�� �
g) Dimensions o6 Proposed Structu V�'idth: � Depth: �
5) Water Supply Type: Private;lj�;new�r existing 0), Public 0, Community �, Spring ❑
Are any weils on adjoining property? Yes � No � It yes, location
c41C¢.� `�" (�.9� o� ►'� 0. d( r-�-
1� 6) Plea�e Indicate D�ire System Type: (systems can be ranked tn order of your preferencal
n
,�Conventional �Modified Conventional _ Altemative Innovative
Other (specify): _,_
�_
_% CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY.
STAKE TNE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SRE PLAN TO THiS APPLICATiON
I hereby make application to the Person C;ounty Health Department for a site evaluation for the on-site sewage disposal system for
the above-described property. I agree tliat the contents of this appiication are true and represent the maximum facilities to be
placed on the property. I understand if the; site is altered or the intended use changes, the pertnft shall become invalid. I understand
that a pplicant, I am responsible, for identifying and marking properry lines, comers and making the site accessible for tF►e
per nn I of the Person County Health D�:partment to conduct their evaluations. I understand that i am responsible for notifying the
alth j�e ment if my property c ntain:� any wetlands as designated by the Army Corps of Engineers.
� �.�� _ �ag/r o
- 0 ner or Legal Representative Oate
.
. . .....�n __.. .ni��me
PLEASE SEE ATT
Tax Map #: _! �
Zoning
Appiicant
Locatlon:
IL AREA AND SYSTEM LA
Parcel # � � �
Township r'aL ^���'r
�ri t1G �-C7� a11.�
Subdivision: �Kr� "� 1 ��-rC.jSecUon: Lot: �`'�
Improvement Permit
A buildinq permit cannot be issued with onlv an Improvement Permit
New� Repair _ Addition _ Type of Structure NI�' Water Supply �tiVa�C. Wt I I
# of Occupants # of Bedroorris � Other �
Basement? Basement Fixtures?
Projected Daily Flow: � g.p.d. Permit Valid For: Five Years ❑ No Expiration
Proposed Wastewater System pe: CA�1VCi1�l 0(1G, I �Y��- �
Pump Required? Yes �No
Permit Conditio
�Fo cr�
Owner or Legal
c�c,p 5cp�i c v' ��o
T
; . /0�' Frflm cl(
Authorized State Agent:
bl,�� ld �
►tciF
i bt c
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Date: 3 � � d�
Date: � o?i�— D�
The issuance of this permitwy the Healfh Department in no way guarantees the issuance of other permits. The perrnit
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 cha�ges. 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 Building Permit)
Type of Wastewater System C��VC,fI'�i 0/)G,� Wastewater Flow: 3��g.p.d.
Facility Type: M�� Le- Home,
Basement? O Yes o
Wastewater Svstem Requirements
New'0 Repair OExpansion��
Basement Fixtures? 0 Yes (�'No
Septic Tank Size: i� Ol`�O gallons Pump Tank Size: N� gallons
Total Trench Length: � feet Maximum Trench Depth: � 0 inches Aggregate Depth: roc in.
Maximum Soil Cover: � inches Trench Separation: I Feet on Center
otne�:Na.uc, Sc��c �wc �( Con-�rar,tor �Cet t�n � vi�t� Prior�ta i n5tr ((c�t;on
Permit Expiration Date: � � d ��
Authorized State Agent: Date: �o�� "'oC�
The type of system per tted O does Q s not differ from the type specified on the application. I accept
the specifications of this permit.
�.��-� .3— �-d c�
Owner/Legal Representative Signatur :� Date:
PCHD, rev/ 10l12/99
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Application #: „
Tax Map #: F}��
Parcel #: ��
Person County Health Department
Environmental Health Section
SITE SKETCH
NOmc Max �a K �� dq c(�c�c�s a 4
Appiic t's Name Subdivision/Section/Lot#
� � J�� �OL
Authorized State Agent Date
System components represent approximate contours only. Tlse contractor n:ust fl'ag the system
prior to beginning tfie installation to insirre tltat proper grade is maintained.
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Scale:
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PCHD, rev. 10/12/99
�
0
. . • • Persori Caunty Healtl� Dep�rtment �
. Env3ronmentai Health Section '
' - Tax Map #: � �� Parcel #: 3� �
Zoning:
Township: 1���� R' UCr
Subdivlsion• DaK�� dq� �CrCS Section: Lot: oi�
m
.�
Applicant: �n'►C%nG-�C
Location• }�u �� ��ad
,
�` O eration Perm it
System Type (In Accordance With Table Va): �
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
HORIZATION.
r , 4 1( "VlJ
Authorized State Agent Date
Tax Map #: ��v
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4'
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Parcel #: 3��
PCHD, rev. 10/12/99
�
, • . . • ., -
Person County Health Department
Environmental Health Section �at �� �� r
Zoning: Township: �
Subdivision: �.� xr r ciq� ��G� Section: Lot: a¢
Applicant: �� mc rna x
Location: {-�u F� 2c�a d
Operation Permit
1. LOCATION AND SEPARATION DISTANCES /
A) System meets .1950 setback requirem�nts ✓
B) Distance from system to any welis o_
C) Distance from septic tank to foundation !�
D} Distance from system to property lines I D'
2. SEPTIC TANK
A) Visually inspect the exterior walls and top of the tank _�
B) Visually inspect the interior walls, ba e, tee, fiiter, riser, lids, air vent,
bottom, and water tight outlet �
C) Date of tank manufacture I o
D) Tank se�ial number 5T6 !�
E) Liquid capacity of tank ID� gallons
3. SUPPLY LINE TO T CHES
A) Grade � (1/8 inch per foot mini��m)� O P�G
B) Material suppl line is constructed from
C) Diameter
D) Length ,S� NI�
E) Distance from tank to drainfield/distribution device
4. DISTRIBUTION DEVICE(S),��
A) Type /U .
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 � mches
B) Trench width �inches �
C) Distance between trenc s
D) Number of trenches , , �
E) Length(s) of trenches ��C�'i (a� � ���,.1 ae��,�'
F) Aggregate depth �_. inches
G) Aggregate material and size �
H) Record septic tank out elevation
I) Trench grade � (< 1/4" per 10')
J) Step downs �
a. Minimum of 2' of undisturbed e
b. Proper rise over step wn �
c. Sofid 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
� � PEi2SON COUNTY ENVIRONeJIENT�IL HEALTH
�� PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
' � � V Parcel # `� O �
Tax Map �J:
,
Zoning
Applicant: � 1 • � ��
LocaUon• � ��'rM� �
Fl�t R, �c.r
Township
Subdivislon: ^C� � �' ��� SecUon: Lot: � �
Well Permit
Tvpe of Water Supplv: ]� Individual Community Public
Re4uirements:
Site Approved by �l + _
Grouting Approved by �/ •�t N 4-��� D
Well Log �►�►+ - -�O
Well Tag
Air Vent
Hose Bib
Concrete Slab
Well Driller: k��
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:
PCHD, rev. 11/29/99
Date: � -C�- �v
Owner: `�
Location/Dire
ions:
PER80N COUNTY ENVIRONMENTAL HEALTH
• •
WELL LOG
0
SR#
Subdivision �Name: .___ ,� f( 2�s S.� Lot #��
Drilling Contractor: � � �c
WELI. CONSTRUCTION
Distance from Nearest Property Line 1 v Distance from Source of
Pollution ( G a ,
Total Dep.th: � U Ft. Yield: � GPM Static Water Level a.r' Ft.
Water Bearing Zones: Depth f�-� Ft. /s F[. Ft� Ft.
Casing: Depth: From 6 to �G' 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 SandJ�ement. / Concrete
Annular. Space Width Inches
Water in Armular Space: Yes No
_ .. Method: Pumped � - Pr:ssure � Foured � . _ . . -
Depth: Fr�m O to r,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 � No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY THE PERSON C^vui1TY HEALTH DEPARTMENT.
i :��f �"1��n� �/-�-�
Signat� of Cont ctor Da�e
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