A40 30702/08/1999 13:49 5971799 PLANNING AND ZONING
� �u�Sy p�zuoy�nb► �e a�uMp i'�S . .
�
PAGE 01
-pa�t��o,� p}Qd s��� 11E P� P�o� �u�o�� il8us uou�a�ldd� �fyi •�d�Q y���H �y� �Cq o��s �y�
�o uopEn1En� oqt ,�o o��p �tn s�1�E SA�Q 09 v'.c�i�" �d�Q ��H �q� ot �v�doJd �� �o �e�d �a�ns � po�sn�Iop
u ��Qq I �u�,�� oq� ui �Q� pcn�s��pun I •�d�Q �I�H �yl o� �uxio.�d �yi �o ���d ��n1ns E �u��d �sntu Y •panss�
u� >>uu�d s�uowono�duri uE o�o��q ��e� pu¢l�opun I•p�IaAuj �wo�q ligqs �tuu�d �ui 's��ueu� �sn p�pu��vr
�y� Jo p�»js �s} ��?s �t�;i puels»pun I��u�daJd ot� uo pr�atd �q o� s�nt�t��e� tunwix�w �� �uo�Jd�s pvE
�n» � uo�����tddE s�y� �o s�u�;uaa �y3 �ey� ��i�E I'�i.1�41fI �U�S'?p 7AOQ� 71� 103 CUO7SI�S 1BSDt�SJp 7SBM7S
s•ua �� �03 uos3Enicn� ��?s E 10� �uatu�.�EdaQ �IEa� �uno� vos.�aa �y� o� uorlE��jdd� �xEu� �q���� I
- •s�nx.i.s a�soaoxa
z�� �o sx�o� �xz au� �.��aoxa �sz 3a s��o� ��� �'ss �����
:p��u�s �q o1 �lao�d Jo s7uQdn��o �o �aqtunH •g
,s�x� �u�waseq � o�`os � D ox j] s��, ��u�tu�s� g
p a11 [] �J� �iEsods�Q �BEq�uJ
--- :�u�toospsq�o �aqcunH
---:rn�Co�dutg �o saquinH�
:ssau}m43o xi�s,
fl:ss�uisng D:��o�.; �I1qoy,I,� .�mo..�
:8 ,ufj��Mp �o �dl�,
; :�vnsix�� -�asodosa :,�rlt��3nsn��N:s �a ad/1, -pj
u
� v '' `' � ' ` � '���'•s�tuE�
P�a�i � # P4O2I ���S :�u�do�d o� svonxnQ . �
�h
�°7
J a .r :dt�Stihn0l,
' ��t=�d
n N #��ys xE T
- . ':rrts �o� :tIG]7aL�i'�Q I►137�OJd .
:uo����al ��pu�pt �os � _ � ✓ .� q � ,
,� oh J sa�,��:a�do�3 ouiu�afp� uo s�loM �u� :s�' . G�/ �//'� '__ Y_ �
r ouvcs �] ��iunur,uc� 0 �tlqnd �• $���nv3 u � �� � � � • /,w � ��j �
:�d.s� /I 'o�ns ::�E fy •6 :»uMo �u�.u::�' � o sS�Jpp� puQ �•.:.TEH .
:r �uoua s5aU15R�
(fJ(/ � / � -�y /� � :tt ^.UOL�G �L']0�
�NaS 0� �-pL��u� s� wa:s�{s �ts�:s�p �a�n�:s sr;:� ?2t,^.
F�iii��; �c �1T::�i11JS :.u� a� pa:2�:�t�a¢ s> >u:c;::��lco�
�o �svoisv�dx� •suontpp� �i.u� �i) �3�> >E�:h1 '8 e ,�,�i G�� o �I n �d
:���c�Q � ( ' �( t" �: �; G` c ti �' :ss �a
:�l�t j•!� ul� j u/ � � :1L�� �;',=Cm� �nt;�a�S��� :�un�t
:��n»;z.�7S p�so_o.d �o suo�SL:;:��Q •� ' ° - :�e p.:s:nb:s �;�,.�
p�a.�-- �pt�r�s:.d � � t:::.�jos7a� — ir�iw�y�— , Eu�:�zg —
s{".�7^^ 4 i� � .d7if��j"�.,�' 'S"'_""�'� �H r� � e+-G:��:'�.-^�„�•- �:i :T�i•
.,., ..�t'"-=;�-�.�..�,i-'" ,,..�;^:�;'���p?:�'��IIo�a4oz:aidia�,za�c {:�.�.-���' ,;.s�:�,� ��.u..,.:..,�,� •:;.
J�'• _`� •� .:rs'r''� �+a�-� ..a:_• .r' �t+. .�. �"SS_ �"'� ..A�h +T1:"'�•, :en..:
�?r+✓'.. w �l._N-: wt`,T'�:. .wt :
i1�M �ut�stxg :����o� —� . (uotl�PPt') »c:i:�d �uau:�noadwl —
1(�A� M�N.1�� i1L'L'�d'_"I (a��ido� �uioH ��iqo)�) �Tt::s�a s�L�u�7�o�dwJ �
u»>s�fS �i��aS Dui�s;x� ��E�do�J�rco� ""'I (�o'I F�P�o�»ujl) �,nu.:n� s�uaw�nQ:�w�
utso�� uro-�) ui��sr S Butis:x� �o uot:�dsus:� —(�07 p�plo��/p�usr�q�Ts�,.,,) �i�sd s3u�tu�no�dv.:7 �)
• �"-`vl���i:�� �� ,�� _
� � r • . .
a�pp
����—G 5��� �'l
;
�
ti
y�. �„� ' ' ��(� ir���a/'ti.�J. I
'��,11%�.� rrt'�r� 1`i:i�1�.J .
: L l Iti...� «.i �(.�'
1�' I I o►�� t
� , � ��z����.
n0 0�� F:Fd :unowN .
" � � C�—��
, ' A�� , cation Date:,��---
, Amount Paid: _��:�_
� Receipt #•
i.._. . . _ _ .
Tax Man #:
Parcel #t•
Person Countv Health Department
Environmental Health Section
. APPLICATION FOR SERVICES .
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED CHANGED OR THE SITE IS
ALTERED, THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHAIL BECOME INVALID
1) Permit requested by: (Owner/agent/prospective owner): �.u�dda X
Home Phone: Addresr 3 q�t c'��, �hc�.,,� ,�d
Business Phone:C33G,i 3h3-R�$'� �n��; N. . 2� � � / � �
-7-
2) Name and address oi cuRent owner:
b S"'7
3) Property Description: Lotsize: Township: ���y��L. �-
Directions to the proper�r (Including road names and numbg�s}: �D/ �v� 2
„ ,
�
r�c. F/� �f- il, uc.r2� . _ .
4) Proposed Use and Structure Description: answer each of the following questions:
a) Proposed'� Existing ❑ .
b) Stick Built 0, Modular �, Single Wde 0, Double Wide�
c) Number of Bedrooms: � d) Num er of occupants or people fo be served: �
e) Basement: Yes 0, No'�yf yes, # of basement fixtures:
� Garbage Disposal: Yes 0, No�O
g) Dimensions of Proposed Strudure: Width: � Depth: � - �
5) Water Suppty Type: Private �(new�or existing �), Public Q Cammun'�ty �, Spring � -
Are any welfs on adjoining propecry? Yes ❑ No 0 If yes, location �
6) Please Indicate Desired System Type: (systems can be ranked in order of your prefe�ence) '_
� �Conventlonal ��Modified Conventional ; _ Altemative _innovative
Other (speclfy):
-% � CLEARLY STAKE ALL CORNERS AND UNES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROPOSED STRUCTURES.
PLEASE ATTACH SURVEY PLAT OR SRE PLAN TO THIS APPLICA710N
I he�eby make application to the Person County Health Department foc a site evaluation for the on-site sewage disposat system for
the above-described property. I agree that the contents of this application are true and represent the maximum facitities to be
placed the property. I understand if the site is aitered or the intended use changes, the permit shall become invalid. I understand
th s a plicant, I am responsible for identifying and marlcing property lines, comers and making the site accessibie for the
erson I of the Person County Heaith Department to conduct thei� evaluations. I understand that 1 am respansible for notifying the
Heait rtment if my prope co tains any wetlands as designated by the Army Corps of Engineers.
vrY3 - _�D
� wner or �egal Representative Date
pLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAYOUT
Tax Man #: / ��0 Parcel # 30
Zoning Township � "
Appiicant: ��-r� iti�O�r
Locadon: ���� ��Fr �� S/d on C
Subdivision:�Krfc�QC.��✓ Sectlon:
jUCr
�
Lot: �
Improverr�ent Permit
A buildincl permit cannot be issued with onlv an ImRrovement Permit
New,�Repair _ Addition _ Type of Structure �� Water Suppiy�ri Va-f.� ��' «
# of Occupants � # of Bedrooms 3 Other �
Basement? �_i-Basement Fixtures? s�
Projected Daily Flow:� g.p.d. Permit Valid For: ive Years ❑ No Expiration
Proposed Wastewater System Type: �iOnUCft�i0114.� l7i'at1 if�l �
Pump Required? Yes •� No
Permit Conditions: KC� S���CM ,�(7' From a,�1 (,�e �( 5� i�' �rom p roP��-�' !� nCS,
�`� FF hcA.� I d��� ��c n da-f,1 c�rv�)�LS' �i-o m d��c-� .-� Mcc,t � e-Fs �n S+fx- �
Owner or Legal
Authorized State Agent:
Date: � ��-U`�
Date: � I ����
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 Buildinq Permit)
�
Type of Wastewater System �D� Ven�c ona Wastewater Flow: �a(7 g.p.d.
FacilityType:MDbl �G �"f��'1'C-
Basement? O Yes 0'I�o
Wastewater Svstem Requirements
Septic Tank Size: �! ��� gallons
New C�Repair OExpansion ❑
Basernent Fixtures? 0 Yes O'�
Pump Tank Size: N I!� gallons
Total Trench Length:'4 � feet Maximum Trench Depth:c��l inches Aggregate Depth:�e7 in.
Maximum Soil Cover: %�, inches Trench Separation: 1 Feet on Center
Other:+�(IVC, J�i�Ou.�d b� �(ls"tQ'��� �.v Sh�(,J�1 Q!1 �jl'�u'rI�C'�G�1
Permit Expiration Date: ��� a��s
Authorized State Agent: • Dated�� 7��D
The type of system permi ted ❑ does l� does not differ from the type specified on the application. I accept
the specifications of this permit.
Owner/Legal Representative Signatur • � Date: �'r�
PCHD. rev/ 10/12/99
Application #: _
Tax Map #: 19`IO
Parcei #: ,3�-7
Person County Health Department
Environmental Health Section
SITE SKETCH
�� {-%orn�,M ax OaKr�d � f���s Z�
Applicant's Name Sub ivision/Section/Lot#
a-� �-o�
Authorized State Agent Date
System components represerrt approxin:ate contours only. The contractor n:ust flag tlie systent
vrior to beQinnin� the installation to insure tliat proper grade is maintained.
�w�F �� � i � cl. � a�K L/� N C—
-RoP�
��rive W0. needs -�o b� in�5 I(�
Scale: I��� C� O� i r1 ��''c- �P P ��P i�=�--E't 1 o cra-�� c� -�
PCHD, rev. 10/12/99
pLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAYOUT
Tax Man #: / ��0 Parcel # 30
Zoning Township � "
Appiicant: ��-r� iti�O�r
Locadon: ���� ��Fr �� S/d on C
Subdivision:�Krfc�QC.��✓ Sectlon:
jUCr
�
Lot: �
Improverr�ent Permit
A buildincl permit cannot be issued with onlv an ImRrovement Permit
New,�Repair _ Addition _ Type of Structure �� Water Suppiy�ri Va-f.� ��' «
# of Occupants � # of Bedrooms 3 Other �
Basement? �_i-Basement Fixtures? s�
Projected Daily Flow:� g.p.d. Permit Valid For: ive Years ❑ No Expiration
Proposed Wastewater System Type: �iOnUCft�i0114.� l7i'at1 if�l �
Pump Required? Yes •� No
Permit Conditions: KC� S���CM ,�(7' From a,�1 (,�e �( 5� i�' �rom p roP��-�' !� nCS,
�`� FF hcA.� I d��� ��c n da-f,1 c�rv�)�LS' �i-o m d��c-� .-� Mcc,t � e-Fs �n S+fx- �
Owner or Legal
Authorized State Agent:
Date: � ��-U`�
Date: � I ����
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 Buildinq Permit)
�
Type of Wastewater System �D� Ven�c ona Wastewater Flow: �a(7 g.p.d.
FacilityType:MDbl �G �"f��'1'C-
Basement? O Yes 0'I�o
Wastewater Svstem Requirements
Septic Tank Size: �! ��� gallons
New C�Repair OExpansion ❑
Basernent Fixtures? 0 Yes O'�
Pump Tank Size: N I!� gallons
Total Trench Length:'4 � feet Maximum Trench Depth:c��l inches Aggregate Depth:�e7 in.
Maximum Soil Cover: %�, inches Trench Separation: 1 Feet on Center
Other:+�(IVC, J�i�Ou.�d b� �(ls"tQ'��� �.v Sh�(,J�1 Q!1 �jl'�u'rI�C'�G�1
Permit Expiration Date: ��� a��s
Authorized State Agent: • Dated�� 7��D
The type of system permi ted ❑ does l� does not differ from the type specified on the application. I accept
the specifications of this permit.
Owner/Legal Representative Signatur • � Date: �'r�
PCHD. rev/ 10/12/99
Application #: _
Tax Map #: 19`IO
Parcei #: ,3�-7
Person County Health Department
Environmental Health Section
SITE SKETCH
�� {-%orn�,M ax OaKr�d � f���s Z�
Applicant's Name Sub ivision/Section/Lot#
a-� �-o�
Authorized State Agent Date
System components represerrt approxin:ate contours only. The contractor n:ust flag tlie systent
vrior to beQinnin� the installation to insure tliat proper grade is maintained.
�w�F �� � i � cl. � a�K L/� N C—
-RoP�
��rive W0. needs -�o b� in�5 I(�
Scale: I��� C� O� i r1 ��''c- �P P ��P i�=�--E't 1 o cra-�� c� -�
PCHD, rev. 10/12/99
• Person County Health Department
' : ,� Environmental Health Section
� Tax Map #: _ !-1 �{� Parcel #: 3a7
Zoning: Township: �
Subdivision• f'� �� Sectlon: Lot: �
Applicant• • �2�0� ��/1
Location:. �
■ ��/) 5�z�`�`' •
O eration Perm it �
ccordance With Table Va : �r� �. ' ���
System Tyre (In A )
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.
S-3 " �" `�
Au orized State Agent Date
� � � da �
��
-�ank;n�
��-5 �poO
s76- �y�
a-1s-99
Lan�
Tax Map #: ,� � Parcel #: 3� �
PCHD, rev. 10/12/99
:
.
Zoning:
Subdivision:
Applicant: _
Location:
Person County Health Department
Environmental Health Section L
Township: �l� T �.'v�--
�ction• Lot• � �
Operation Permit
1. LOCATION AND SEPARATION DISTANCES
A) System meets .1950 setback requirements �
B) Distance from system to any wells �- �op
C) Distance from septic tank to foundation S�
D) Distance from system to property lines o``�
2. SEPTIC TANK
A) Visually inspect the exterior walls and top of the tank --�J
B) Visually inspect the interior walls, baffle, tee, filter, riser, ids, air vent,
bottom, and water tight outlet X'`V
C) Date of tank manufacture �� 5- 9 9
D) Tank serial number s /�
E) Liquid capacity of tank l� � gallons
3. SUPPLY LINE TO TRENCHES
A) Grade e,� o�►� (1/8 inch per foot minimum)
B) Material supply line s constructed from .s�!► ya Pu�
C) Diameter 3 ''
D) Length y '
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
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 �_ inches
B) Trench width �1� inches n/��
C) Distance between trenches `% T�
D) Number of trenches � � � � , �
E) Length(s) of trenches D` 9 b �D (D6 .= y% y
F) Aggregate depth I inches
G) Aggregate material and size S-�
H) Record septic tank outlet elevation
I) Trench grade (< 1/4" per 10')
J) Step downs
a. Minimum of 2' of undisturbed earth
b. Proper rise over step down
c. Solid pipe used
d. Elevations of step downs (Record elevations and show on as built)
See "as built" plan on attached sheet.
PCHD, �ev. 10/12/99
' • PERSON COUNTY ENVIROIZMEttTAL HEALTN '
� ., . ' - •
_, � • • ..
Date: � 8 00 '
Owner. �C���V�►�
Location/Directions:
WELL LOG '
SR#
Subdivision N�une: �� �`1���C C'. �� Lot #
Drilling Contractor: '
WELL CONSTRUCTION —
Distance from Nearest Property L�.n� 10 Distance from Source of
Pollution 1 CX'� '
Total Dep.th: IL�� Ft. Yield:�d ___ GPM Static ��ater Level ��_}=�.
Water Bearing Zones: DepthSS rt.l�� _Ft Ft� �t.
Casing: Depth: From d to�_Ft. Diameter:_ 1�,, _�ch�s
TYPE: Steel - GalvaniZed Steel _/
, If Steel, does owner approve: Yes No
� Weight: Thic};ness:�_ Height� Above Ground:�_ Inches
I?rive Shoe: Yes ✓No .
Were Problems Encountered in Setting the Casing? Yes No L�
If "yes" give r�ason:
Grout: Type: Neat Sand/Cement ✓ Coricrete
Annular Space Width Inches
Water in Annular Space: Yes No
_ .. Method: Pumped � - Pressure � - Poured _��. � � �. .
Depth: From� to_ � t� Ft. . .
Materials Used: No. Bags Portland Cement Weight of .1 bag__lbs.
If mixture (sand, gravel; cuttinos) - Ratio: to
�ID Plates: Yes_� No � � � � �
�� 4 x 4 slab Yes No
r HEREBY CERTIFY THAT THE ABOVE TNFORMATION IS CORRECT AND TH AT
THIS WELL WAS CONS�'RUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERS0�1 C�Li�'I'Y HEALTH DEPARTMENT.
� d�-._--
ignaturc of Contractor Da�c
n
PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
• Tax Map #: � �O Parcel # v `� �
Zoning
Applicant: �� M t' � v"�
Locatlon:
Township 1 / �'� ' "1 U �r
� j( �
Subdivision: �' `r� �� t' ��SSectlon: lot:
Well Permit
�ae of Water Supplv: ✓ �ndividual Community Public
Reauirements•
Site Approved by i� ' 3�*�
Grouting Approved by /?�� 3��a
Well Log �"%' 3 �a-�
Well Tag �?r�� 3-�� - �
Air Vent ,fhP-�'' 3�- �
Hose Bib �-�' 3 -� -�
Concrete Slab ��',- .3--��-�
Well Driller• �
Well Approved By: --5' �
Date: �— � � Q
**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.
Ke� t,�c-1( I�� ` F�orn 5 ti �
Other conditions: �P �"i
PCHD, rev. 11/29/99