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PLEASE SEE ATTACHED PLAf�
7axMap#: , 1��
Zoning
Appilcant: f�'� aw^ � � J
Locafion: S 7 J � U F� �
Subdivision: �r� �Cf Gs SecUon:
FOR SOIL AREA AND SYSTEM
Pe�e� # 3a3
Townshfp ���t I�t �l C r
i n.S � an t
Lot: �S
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Improvement Permit
A buildina permit cannot be issued with oniv an Improvement Permit
New � Repair _ Addition _ Type of Structurei�i� Water Supply �r��at��C I f
# of Occupants�R1G.X. # of Bedrooms � Other •
Basement? �i O Basement Fixtures? O
Projected Daily Flow: ��g.p.d. Permit Valid For: �lFive Years ❑ No Expiration
Proposed Wastewater System T e: I u�G � C'nrivell'�� �G� I�
Pump Required? Yes �N�
PermiYConditions:� L%J� �¢�� Dl u�S F�m ct.nv vco�� Sy6��c m. Kec� s�.�tcm
%Dc,� -! �`n �t r�cc ,��'"n l l 0.S Flcc. rG a� U/1 JD �►:I�` � /i � cs on Coe'rEou r
Owner or Legal Represe iive Signature: Date: �"-�3'"6D
Authorized State Agent: Date:� " � �
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 Buildina Permit)
Type of Wastewater Syst�mCO� VU1�vnA. �iWjry 1Nastewater Flow: o� g.p.d.
Facility Type: mObl l� '�flM New$ Repair OExpansion ❑�
Basement? O Yes 0 o Basement Fixtures? C] Yes C�f�lo
Wastewater Svstem Requirements
Septic Tank Size: � i ��� galtons Pump Tank Size: ��1� gallons
Total Trench Length: `1�� feet Maximum Trench Depth: �. inches Aggregate Depth:� in.
Maximum Soil Cover: �, inches Trench Separation: �1 Feet on Center
otn�/�l�t EH�San 5���� Arr�or f-v i�✓t�.fla-fa'o�� F�Iloc� IaY�
Perrnit Expiration Date: �'"� �D �OCZ�� �
Authorized State Agent: • Date: ��l � J �o
�roV idk� �
The type of system perm ed O does Q does not differ from the type specified on the application
the specificatians of this pertnit.
Owner/Legal Representative Signature. Date: 6 a 3 G v
I accept
PCHD, rev/ 10/12/99
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Application #:
Tax Map #: � ,
Parcel #: 303
Person County Health Department
Environmental Health Section
SITE SKETCH .
� Oa.Krid � AGrc�S a?S
�c�mmv �otcJKinS —
Applicant's Name Sub ivision/Section/Lot#
�—/9-oc�
Authorized State Agent Date
System components represent approximate contours only. The conlractor must, flag the system
nrlor tv be�innin� the installation to insure tltat proper grade is maintainecl
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PCHD, rev. 10/12/99
� PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: /"f �v Parcel # ���
Zoning
Township F/ Q� '`� V C. ('
qpplican� �m m y �"�Cl(.�� � 11,5
Locatlon:
Su6division• �an r� d 9 G/'ICrCS Sectton• ���
�pe of Water Supalv:
Reauirements•
Well Permit
�Individuai Community � Public
Site Approved by � n� �+ �- 7-oo
Grouting Approved by n� � - -a�
Well Log �5►� �+ �- -cu
Well Tag
Air Vent
Hose Bib
Concrete Siab
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• . . . - . . . ...Il .%1 .�1 �.�// . .
*'"'See Attached Site Sketch�`*
Welis must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Weiis must be at least 25 feet from any buiiding foundation.
Other conditions: Ktx� wc-I l�.oO� AIu�S F�orr,
�n.4F-f.11 �,�h�rc�, ,S�►own On <
PCHD, rev. 11/29/99
Date: f-�Q-� '
Owner.
Location/Directions:
Subdivision Name:
Drilling Contractor:
' ' PERSOft COUNTY ENVYR6NMENTAL HEALTH
WELL LOG
.
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Lot # c�, 5�'
. WELL CONSTRUCI'ION �
Distance from Nearest Property Line ! v Distance from Source of
Pollution ( G o
Total.Dep.th: oZ�D Ft. Yield: y GPM Static Water Level a?.,s" Ft.
�
Water Bearing Zones: Depth /y5 � t F� � Ft� �t.
Casing: Depth: From 6 to ' Ft. Diameter: Inches
TYPE: Steel � alvanized Steel �
If Steel, does owner approve: Y�s No �
� Weight: � Thickness:�_ Height� Above Ground: j�i . 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 Amiular Space: Yes � No
_ _. Method: Pumped � - Pressure � - � Poured � � - . :
Depth: From � to O 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^vtJi�'T'Y HEALTH DEPARTMENT.
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Person County Health Department
,q-�1� Environmental Health Section
Tax Map #: / I`f V Parcel #: ���
Zoning: Township: ,���� ���
Subdivision: Section: Lot: ��
Applicant:
Location: �� � �� I tl�l I � �l �� ���'� l (,�,� �I L ���1.-{ Vt-�� �
Operation Permit
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
AUTHORIZATION.
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A thorized State Agen
7-(�-D�
Date
i ,� ,(v'►
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5 ��� �, I V1�l.Dl�cE�
,;� ►r
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Tax Map #: I� "�v Parcel #: �b ✓
� 115 ��
2 � 25
I I 5'
I 2v'
�75'
PCHD, rev. 10/12/99
Person County Heatih Department
Environmentai Health Seciion
Zoning: Township: �Gl,� �� �ir
Subdivision: �a�� �, �� Section: Lot: %�
Appiicant: ;�����`�a.w�� �s
Location: �� P �,p ��J
Operation Permit
1. LOCATION AND SEPARATION DISTANCES
A) System meets .1950 setback requirements �_
B) Distance from system to any wells �100'
C) Distance from septic tank to foundation (n'
D) Distance from system to property lines y10 �
2. SEPTIC TANK
A) Visually inspect the exterior walis and top of the tank ✓
B) Visualiy inspect the interior waiis, baffle, tee, filter, riser, lids, air vent,
bottom, and water tight outlet ��
C) Date of tank manufacture �-0
D) Tank serial number � 0 —
E) Liquid capacity of tank I 0��_ gallons
3. SUPPLY LiNE TO TRENCHES
A) Grade (1/8 inch per foot minimum �
B) Material supp�y line ' constructed from �
C) Diameter
D) Length 3 �
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
� 1 D) Is the device on a level foundati�n
� � E) Ooes 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 trenches � q� 61/1 i i�Vl��
D} Number of trenches
E) Length(s) of trenches
F) Aggregate depth �_ inches _' n
G) Aggregate material and size • 't�
H) Record septic tank o ttet elevation 1[�1
I) Trench grade � Il�IG L 1/4" per 10'�'
. J) Step downs �J
a. Minimum of 2' of undisturbed earth �
b. Proper rise over step down ✓
c. Sofid pipe used _,�
d. Elevations of step downs �(Record elevations and show on as built)
����f
See "as built' pfan'"o attached sheet.
PCHD, rev. 10/12/99