A40 304s
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s
PDDIIGtIOfl D�: �-oo
Amount Pdd• , o� •
R�sio� �k ��L�
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Persao Courtiv Heaitfi Deaartmerrt
Errvironmental Heaitt� Saction
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1F THE INFORMATION IN THE APPUCATiON FOR•AN IMPROVEIV�ENT PERMIT IS FALSIFi�. CHANGED OR THE S1TE lS
A�TER� THEi�I THE IMPROVEMENT PERMIT AND AUTHORiZA'TION TO CONSTRUCT SHALL BECOME INVAUD
1) Psrmit �a�ed by: (Ornrttetia9eMlP�+osPacttve ovmerl. Sf�n� m Y �Aw /�.n�c
Homs Phon� _ 3 C� �-Sl' � • A�d� �� s'S � R 4 L� �ii, �'`s
Btnirl0as Phone: ' /,� a �y� „ /�►n ,q„C � �.
Zj Na�tte and addtess ot currs�tt �owner: �`
3) PropattyDescrtptioc� Lotat� ��a�`'Ta+r�p: .'P• �/��D
Diroc�iate ta the P�P�Y ��9 �ad nama and numbe�a}: /V
4) Pcoposed Usa and Struct�sre Desarlptlam anawa� ear�► af the �o0owing que�o�s;
a► �Po� 4 E�dsti� ❑
b) Sli�Cdc Bu� q Moduiar G. Singla W(de 4 �auble Wide 0� c(
� Number of 8edrooms. c� Number oE occupants oc peopie Eo be secved:
e) 8aaement Yea 0. No yea. � of basemert fix�ucax
•� Garb�ge Diaposa� Yes 4 No�' •
� Q�.o� w�o�a sa�: w�m,: �-� o� 6�
6I W�' s�PPhl �� �B'(� a ac �sUc�9 Di� Pt�cO. Cocmnu�Y O. Sprin� 0.
Aro any wapa on adjoin��g propaiY? Yes 0 No 0 lt yea, loca�on
6j Pl�as� Indicad D�aiisd Syatom lype: (syatems can bs raniasd ln ac+d�+r of Y�' P�)
vC�ve�itional Yodifled Cotnraetional _ Aibrt�a�vr �nnorative .
o� hp+di'y): :
CLEARLY 9TAKE ALL t�RNERs AND 11NE3 OF THE PROPStTY.
3TAKE THE CORNEi�S OE ALi. PROPOSED STRUC7URES.
P�EASE ATfAC�1 SURVEY PLAT OR SRE P�.AN TO THIS APPl1CA'nON
�' p
� s� 3
��Y �� tc the Pe�on CouMy Health Departrnent ibr a s�e av�fton for ths cn�ibe sawaqa disPoa�l syst�m
the slbove�acrjt�ad propecty. l agnee tlmt ihe cos�enb af this app�on ats tnse and ro� the ma�drtunn faa�tes io
Pfecad on the �ty. I�u�r�d 'd ths si�e is a�e�ed ar ths i�ncled use c�tas�es. tha pan�t shai becane inwiird. l undoss�
1tt�t as apQBcartt, 1 am �espona�ble fa idaqHying and n�idn9 P�P�Y �, ��d �g the a�e aae�b{s foc
Pe�sonnei af 1he Ccuniy Hes�tt Oe�rtrnetrt to conduct their evakraUoas. l t�ecstsnd tliat 1 am t� �' �9
H�Ith D !f mY P�P�f a��wetlands aa dai�ed bff the ArmY CorPs of EnQnea�s.
�r�1��OJ
� ���wa�a+�VQ . �
PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAYOUT
T.��� �40 �� �aq
Zonlnp _Townsbip FICd-'� �111Gf
�Pi�„n; �am T l-�0.�Jki ns �
�iion:1�S76 /Z IfuFF kd, ��l,�r'Id �K Lanc �f}u.-tz.imn Or, l.ot znd an�
subcu��: c�'Y� Kr i�la� fit,�'�S s.aro�: ��--
Improvement Permit
A buiiding aermit cannot be issued with onlv an Imarovement Pennit
New � Rapair _ Add'�ion _ Type af Strudure �1'F}i Water Supply �ri � �� � � �
# of Occupants 0�''1�i� # of Bedrooms � Other _ -
Basemeni? �—Basement Fixhires? NQ
Projeded Daily Fbw: � g.p.d. Permit Valid For. ji�Five Ysars 0 No Expiration
ProposedWastewater�System� xype: �n��-n-��o�� ����� �r �
Pump Required? Yea V No .
Permit Cond'�fons: �5-E��( 1 i nc 5 a-S Fia�a d�n 1 �`� b y��`fS. Xcc�v Ss�s-E,cdn
u
Owner or Legal
Autho�ized State Agen�
The issuence of this pertni�by the Health DePartmerrt in no way guarantees the issuance of other permits. The pertnit
holder is responsibla for checking with appropriate 9oveming bodies In meeUng their requirements. This � site is
subJeat to cevocation if the site pian, plat, or the Intended uoe changas. The Improvement Parmit shall not be
affecbed by a change in ownership of the sita. This pertn[t is subject to compliance with the provisions of the
Laws and Rules for 8ewage Treatment and Disposa� SYstems of tfie North Carolina Administrative Code.
Authorization To Construct Wastewater Svstem (Required for Build(ns� Permit)
Type of Wastewater SystemConucnE�'on0.� ��aU��Wastewater Ffow: �_ $Q�.p.d. •
Fadlity Type:�'1ab� Ic. /TOmL
Basement? 0 Yes �No
�$ �..,�+p� s..stetr� Reauiremsrrts
New t� RepairOExpansion 0
Basement Fixtures? 0 Yes �No
Septic Tank Size: �� a-',O gallons Pump Tank Size: �/ � 9aUons
Total Trench Length: � feet Maximum Trendi Depth: �_ inches Aggregate Depth:� In.
Minc ^ru,�n^ �
.AAa�lmam Soii Cover. �a inches Trench Seperation: Feet on Center .
Other. Tnv��[ I��-� ( aS S�ac,��� K�v c.�e. r �(� ��Dll.c�5 F�am
Pemtit Expiration Date: � c� 5���
Authorized State Agent: ` Date: �s �
The type of system pe tted D does ❑ does not iffer from the type speciSed on
Sc����
the application: 1 accept
the speciflcatlons of this pertnit.
OwneNLegal Representative Slgnature: Dabe: � Z �
, PCHD, rev/ 10/12/99
. � . • � ' . .
� Application #:
Tax Map #: fl4Z�
Parcel #: `��4
Person County Health Department
Environmental Health Section
SITE SKETCH
� - -
�mmY Na.WKi�S 'ri e. f�-r�s o�(c
Applicant's Name S bdivision/Section/Lot#
• R as-�
Authorized State Agent Date
System components represent approximate contours only. The contractor must flag the system
_�__ •,. c,.,......:..,. �6„ J..��..11niinn i.. :ssc�iro thnl nrnner t�TadE [S mallllll[KelL
ii _ J�� � -
Scale: �
PCHD� rev.10/12/99
' • PeFson County Heaith Departrnent
A Environmental Health Section
Tax Map #: /t� �� Parcel #: [1 �
Zoning: Township: a-'� l�. I�/�
Subdivision:�t�c i� �'iC'� Section: Lot: ��
Appticant: tii%.��'�-
Locatlom r�fi(f� .��� %�C'�•
Operation Permit
System Type (In Accordance With Table Va): �_
THIS SYSTEM HAS BEEN INSTALLED IN COMPUANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORI TION.
f 0�-��,�
Authorized State Agent Date
l� _ � �- 1,0 �v
� TS lo� °
�; vl2 � � I �
a �03
�s� kJ e��
PCHD, rev. 10/12/99
Person County Health Department
Environmental Health Section
Zoning: Township: ��0'�� ��J`2�
Subdivlston: �A�n` �'� ��S Section: �ot: �_
Applicant: �� �1�i v�-�_
Location• � �� 'ttf.�+�' �d(-'
Operation Permit
1. LOCATION AND SEPARATION DISTANCES /
A) System meets .1950 setback requirements ✓
B) Distance from system to any welis ��f'"
C) Distance from septic tank to foundation
D) Distance from system to property lines �
2. SEPTIC TANK
A) Visually inspect the exterior walls and top of the tank
B) Visually inspect the interior walls, ba , tee, filter, riser, lids, air vent,
bottom, and water tight outle
C) Date of tank manufacture — —2�
D) Tank serial number ST 'Z-
E) Liquid capacity of tank galions
3. SUPPLY LINE TO TR CHES
A) Grade (1/8 inch per foot minimum)
B) Material supp� �i�e is constructed from �k � cl ��/ L
C) Diameter b
D) Length '�^ r
E) Distance from tank to drainfield/distribution device �_
4. DISTRIBUTION DEVICE(S)
) Type
B) Is Device water tight
NI� C) Distance from the distribution device(s) to the trenches
� D) Is the device on a level foundation
E) Does the device pertorrn according to its design specifications
F) Record the inlet and outlet elevations
5. NITRIFICATION FIELD
A) Trench depth Z� inches
B) Trench width �� inches � (� ,
� C) Distance between trench s '�t �
D) Number of trenches
E) Length(s) of trenches
F) Aggregate depth �_ inche� _
G) Aggregate materiai and size ��, ���
H) Record septic tank outl t elevation ��
I) Trench grade � � (< 1/4" per 1A')
J) Step downs
a. Minimum of 2' of undisturbed eart�_�
b. Proper rise over step own
c. Solid pipe used
d. Elevations of step downs �(Record elevations and show on as built)
See "as bu�lt' plan� attached sheet.
PCHD, rev. 10/12/99
�
Date:,L
Owner:
Locatio
�ERSOti COUNTY ENVIRONMENTAL HEALTH
WELL LOG
SR#
Subdivision Name: c�, � Lot # ��
Drilling Contractor: � � �c
WELL CONSTRUCI'ION
Distance from Nearest Property Line 1 c1 Distance from Source of
Pollution ( G a
Total Dep.th: � Ft. Yield: v`^� GPM Static Water Level Q?S� Ft.
Water Bearing Zones: Depth �_Ft. F� Ft� Ft.
Casing: Depth: From b to �'.�Ft. Diameter: Inches
TYPE: Steel - Galvanized Steel
If Steel, does owner approve: Yes No
Weight: Thickness:� � Height�Above Ground: I�i Inches
I?rive 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 Annular Space: Yes No
� _ .. Method: Pumped - Pr:ssure � Poured � � - � � -
Depth: Fr�m O to �2 � Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs.
If mixtuie (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 TH AT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON COili�l'�c' HEALTH DEPARTMENT.
tL�1��'�: � �. • � , � �r
. � � • ,��
Tax MaP �: �� _ Parcol M�J v�
Zoning TownshiP�/(�� �I V C�
�P,��� � �m m y {-�a�k � ��
��o�: 5GL �c �m r`t
� a �� ac�
Subdivision: � r / 1 CI'�S gection:
Weil Permit
Tvae of Water Suaplv: Individual Community Public.
Reauirements•
Site Approved by �
Grouting Approved by ;
Well Log � �
Well Tag� 6 3 �
Air Vent 5�d 3� l�
Hose Bib �5 �e 3 r,
Concrete S1ab � s iu �
Well Driller
Vlfell Appro
�
c�►3r
8 ci
Date: � u 3� g�
**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: ��f,n-1 l ����1 � 5�oU'n
PCHD, rev. 11/29/99