A40 305..a . , � _._.
�}cltatlon Date: ��__ o �
Amount Paid: � /—So 4`' .
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Persoe Ccuetv Heaitlt Deoartmeat
Enviroemer�i Heaitl� 3ecllQn
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�) P�rmit reques�ea b: vwnedagont/prospactl,ro owne�:,��
• Homs Phon� � �( aS��-- • q,� �
Bwinaaa Phane: -
Zj Name and addraas of currertt�owner: `�
3� Praparty DsscriQtioc� tat sia� � a� Ta� ��' //
Dirediats to the praperty (Induding road names and nurt�sk �( � FF �.Q,
4) Praposad Usa and Stru�twe Des�ription: ana�re� eact� ofthe fa�owin9 qc�fons:
a? �Po�d 4 6dstlng ❑
b) Sttdc Bu� q Moduiar q Si�e W(de q Dauble Wide A�
e) NBaae� Y��yes, � of basament fixl�uex af ocxx�ants ar peopio to be seive� �_
� t� Garbe6e Disposa� Yes Q No+�/ � �J�,
9I Gt�siatsof Proposed Strucbuna: VVidtt�: a$ Dapth; �
� W�+' �+PPhI �� �cq'inew � oc e�dayn9 �. Pu�6e 4 Cortm�a�Y 4 Spdn9 0.
Are any w�lla on a�oining propat�? Yes 0 Nc � tt yes, loca�on
6j PI� Indtc� O�sind Systiam Type: (syata�na can bs rallo�d tn e� of Y� P�)
�Ccnvetltlon�i Yodifted Connntional _'Alt�rnatht� �nnov�lva
O�e (sp�7f):
-r � CLEARLY. STAKE ALL CORNEFcS AND UNES OF THE PitOP�itTY.
� STAKE TtIE CORNERS OF ALL P�OP08EI! STRUCTURES.
PLEAS� ATT1aCH SURVEY PU1T OR SRE PLAN TO THtS APPl1CATION
��Y ��on to tl�e Pe�on Cami�r Health Departrnm�t ibc a a�e eva�lon fior ths a�sibe sawaqe disPoaai sya�ecn
tl�e above-desai�a� property. � aeree thst �te ��t of this �oc� ace tnm and �d the ma�drtuun � to
Ptecsd on tha pnopecty. 1 und�tand if ths s�e is altered arthe imm�d�d uae �.1he penr�t � becocne inw8d. I�
tltat as ap�BCat�t, I am ttispor�ie fot idantiljMg and rtm�9 P�'�Y i�ues. come�s and making tlte si6e a�ls fot'
H� D� f{ �yHes�h D�trnent io ca�dud tt�ic a+rakmtlons. I ia�etstand tltat 1 am t� ��9
� b71 � �11 �� � �6i�ecs.
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:.. ; ; O�m�' o� R�e . Date
Taz AAap � A� 4 0 �� 3�S �
Zoning _ Township FI0.� K( J�
i ii ..,.. .
APpllcutt: �'�lYl
L,ocatlon: /c5 %c5
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on (K)a-ECc�rntr
s�o�u�wo�: Kri C.rtS s.aio� t.o� oi1
Imarovement Permit
A buildin� aennit cannot be issued with oniv an imarovement Pennit
New � Repalr,_ Add�ion _ Type of Struc�ure(i��} Water Supply Rr� �r� W��� '
# of Occu nt fh0.X # of Bedrooms � Othe�__ •
Basemen� ��Basement Fixhires?��
Projeded Daily Flow:�� g.p.d. Permit Valid For.� Five Years ❑ No Expiration
R l.t.'E�.t. h'1 (1 ,� r� J�
f,� i Id Oa IC Lanc
Proposed WastewateyS�ystem Type: � l.! ltr4 -���t I 1 ot� Co�! ll c n f,r`a na 1
Pump Required? ,� Yes No For Rc pa; r .
PermitCond�fons: �5-[a!( S�st�m �ia�� ��► /at 7�,� S�St�m C�;1! r�ui�z.
-r` (o ``� � a.c,���-��a a/ Co ve r� r'11 6� t-cau� r� � to bt
Cl� ULrcS+`an a�i-�C�,c,S n,5 S��c�rl � , � — u
Owner or Legal
Authorized State
lb�f7/G0 ha� Ic.d
Date: r n ,
Date: / �� 'a �
The issuance of this pem�t by the Heafih DepartmeM in no way guarantees the issuance of other pem�its. The permit
holdar is responsible for checking with approprie►te 9oveming bodies in mes6ng their requirements. This � site is
subJact to irevocation if the sita pian, plat, orlhe Intended use chan9as• Ti►e Improvement Permk shall not be
affected by a change in ownership of the stte. Tf�is permtt is subject to compliance wlth the provislons of the
Laws and Rules for Sewage Treatment and Disposa� 3ystams of the North Carolina Administrativs Code.
Authorization To Construct Wastewater Svstem (Re4uired for Buildin� Permit)
Type of Wastewater System�nn UrIiN'aq r'a�1'Er Wastewater Ftow: y�►�.p.d. •
Fadlity Type: m �D ���C ��� m C . New [� RepafrOExpansion 0
Basement? 0 Yes ,� No Basement Fixtures? 0 Yes�$ No
Ijljgsbewater �vstem Reaulremsrrts Fa� R� � �
Septic Tank Size: �0� �allons Pump Tank Size: ), 0� 9a���$
Total Trench Length: � feet Maximum Tnend� Deptir. .� inches Aggregate Depth: �a In.
m� n � m � ra�Saii Cover. � inches Trench Separatfon: � Fset on CeMer .
Other..T�str.11 (,xl 1 Q6 �S�ac.�rt ,%i �5 v� !/I rU�u i r� �y ,�d F Q�i��a�� �.S�v i/ " I� uc r'
Peimit E�iration Oate: - ��L�P d � ut�S i on d i t�-� a �� F �a �'�' ��� z'
T 5 �c,�n ,
Authorized State Agent: Date: ' - .
The type of system pe � tted ❑ does � does not dlffer from the type specified on the application: I accept �
the specificatlons of this pertnit _ �
OwnerlL�gal Re'ns�ntative 8lgnature: � - L�be: �� � 7 Qd
PCHD, rev/ 10/12l99
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Application #: �
Tax Map #: f��._
Parcel #: ,�2; �,� _
Person County Health Deparlment
Environmental Health Section
. SITE SKETCH
��` Kr r cl t 14t�
�Jamrny �-}a.�,.�kr �.s � Subdivision/Section/� t#
Appii nt's Name
` �a��
Authorized State Agent Date
System components represent approzimate contours only. The contractor must flag the system
nrior to beQinnin� the installation to insure that proper grade is maintained
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Scale: ! ��' �Q ,
PCHD, rev. 10/�12199
p►vcrS��'�
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1 UII W1�e-
2' c�t�-`�
a�,� � ��� c, i
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P `P`'
Person County Health Depactrnent
E vironmental Health Section
.> , ,f n
Tax AAap #: �`7D Parcal #: �' S�
" p.
Zoning: Townahlp: � � a� I� ��%� ir
Subd(vlsion: �a����qe ��S Section: _ Loti O'�
Applicariti �AIMPh.t/ `t�LiWY i n_p
Location. ��Z 9 p�-� ��' R d. � 1�J ti �c�,�fla.� ��. C�o�- o���(�'`� xe r
ap�ration P�ermit
System Type (In Acxordance With Table Va): �•� �-
TH1S SYSTEM HAS BEEN INSTALLED IN COMPUANCE WITH APPUCABLE NORTH
CAROLiNA GENERAL. STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
�AND ALL CONDITIONS OF THE IAAPROVE�AAENT PERMIT � AND CONSTRUCTION
AUTH TIO . �
tl `ot o tJ
� Author¢ed Agettt .i /av ��i lire l/ Date
. . � y
C` �
hR�w
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5� �'�"�
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.��1Jti-g�v�,�� � �Co� ��erS c�`�'�'
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-� � � PCHD, rev. 10/12/99 .
�� -
- � " Person County Health Department
Environmental Health Section ,{- (�^
Zoning: Township: �'�{,1 Il � � �
Subdivision: � �✓'�� �S Section: Lot: �.,�
Applicant: JG i1�tr�c.0 G�.uJ ic.�+� S
Location: /'n�n.o:� � N1.�.lc.�,witi �ir- � Gc,�� �� � -- o.F.� t'�cc-�� ��l —
Operation Permit
1. LOCATION AND SEPARATfON DISTANCES
A) System meets .1950 setback requirements �%�S
B) Distance from system to any welis oa�
C) Distance from septic tank to foundation �
D) Distance from system to property lines �v
2. SEPTIC TANK
A) Visually inspect the exterior wails and top of the tank �e S
B) Visually inspect the interior walls, baffle, tee, filter, riser, lids, air vent,
bottom, and water tight outlet �
C) Date of tank manufacture '7 -!`I - d �
D) Tank serial number S�'l� i'f�-
E) Liquid capacity of tank [ Oo0 gallons
3. SUPPLY LINE TO T ENCHES
A) Grade �'2�rtiw�� (1/8 inch per foot minim�m)
6) Material supply li�e is constructer from Se��• d P�C-
C) Diameter � �
D) Length �/ �
E) Distance from tank to drai�d/distribution device _�
4. DISTRIBUTION DEVICE(S
A) Type JV�
B) !s Device water tight �_
C) Distance from the distribution device(s) to the trenches iV' �4
D) Is the device on a level foundation N!�
E) Does the device pertorm according to its design specifications N�
F) Record the inlet and outlet elevations N�
5. NITRIFICATION FIELD ,L
A) Trench depth �7� inches
B) Trench width �inches � �
C) Distance between trenches �h
D) Number of trenches /�, P
E) Length(s) of trenches �� S`3r Ss��3T���� ��`"0� �'��
F) Aggregate depth � inches
G) Aggregate material and size . �bk S�%
H) Record septic tank outlet elevation 3�/�, S" �`
I) Trench grade �Ce ra.w:lg _(<_ 1/4" per 10')
J) Step downs
a. Minimum of 2' of undisturbed earth �
b. Proper rise over step down ,�- E'�,_
c. Solid pipe used eS ,
d. Elevations of step d�� �'R"�(�cord elevations and show on as built)
See "as built" plan on attached sheet.
PCHD, rev. 10/12/99
P
ERSON C �v � ENVIRONMENTAL HEALTN .�
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax MaP ih. �4 � Parcai i� ��
ZoNng
Township ��'� I�t �i C i
Applican� � M M�/ N"Q W ll i�►�
I.xation: �{�-' �C (' M � .
� � 1
subdlvlsion: �-� ��-r�".� Sect(on: �O� �
TYpe of Water Supplv:
Reauirements•
Weil Permit
�ndividual Community Public
Site Approved by �/`� �6 D'
Grouting Approved y � �
Welt Log / i�s �o a6 0
Well Tag � S 2� Z-�
Air Vent �" 1�- -�
Hose Bib /a `� `�'
Concrete Slab /,1- /a -��%
Well Dritlec: �aY
Well Approved By:
�
Date: �c�- - % c� ` C�U
**See Attached Site Sketch**
Wells must be 10 feet from property lines.
V.yells must be 100 feet ftom septic systems.
Wells must be �at least 25 feet from any building foundation.
Other conditions: �n�S�-ll t,Jti1 �s S�oc...�n on 5���- ��Q� °
PCHD, rev. 11/29l99
Date: I c� -as -� �
Owner: � � �.
Lacation/Directio�
PERSON COUNTY ENVIRONMENTAL HEALTH
� �'
WELL LOG
SR#
Subdivision Name: __ d Lot # a7
Drilling Contractor: � � nc
WELL CONSTRUC'I'ION
Distance from Nearest Property Line 1 v Distance from Source of
Pollution t G a
Total Dep.th: /�/U Ft. Yield: .S � GPM Static Water Level a.S� Ft.
Water Bearing Zones: Depth �F[.�C� F� Ft� Ft.
Casing: Depth: From 6 to.�a Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel
If Steel, does owner approve: Yes No
Weight: � Thickness:� � Heigh[�Above Ground:�Inches
I?rive Shoe: Yes ✓ No .
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" give r�ason: �
Grout: Type: Neat SandJCement / Coricrete
Annular Space Width Inches -
Water in Annular Space: Yes No
_ .. Method: Ptunped - Pr�ssure � Pour�i � . - � - .
Depth: Fr�m O :o �. 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 INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTTH REGULATIONS SET
FORTH BY�THE PERSON CO'Ji�ITY HEALTH DEPARTMENT.
ignatu� of Cont,��ctor
��.
s=: �
Datc
►.