A40 318..� f } p o
• '_-Amount paid ��G.
' Reaeipt f� ' �J��
� I 63 6 6
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PFr.S:.n ��u�ry ��:1lth L��_: •� a b�' 0
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• �oxcoro. N.C. �i�?� � `��� �=�3--d �
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te
..w r = ., � _ ... . =.� � � � �� � e c"s';Requ_'�'e.sf ed� �` ' . K ' : s ;�.�,y�"::�
,�: .� .� �. -S rvic
_�. �,>._,,.,.. ,..xe.`,?. �!;�i,
_ Imprcveme�ts Permit. (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closir
_ Im�ovements Permit (Unrecorded Lot) Repair/Replace existing Septic System
_ Improvements Per*nit (Mobile I-Iomc Replace) Pecmit for �ie�v Well
�_ Improvements Permit (Addition) _ Replace Existing Well
l( 1' !' S't1� S.3 R�l Y .... •�t: �
:�' ; °;�` •`�� ,�, � r r},'�;';.�Yater�ample�fo�be:CollecEcd * �" `° .��� �; -�` �r ����
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. � ....,.._. .... ._ .. . _. .� . . ....._.... -- -- •—•—• - __._ ....._ ._. . _ ,.. .,.. � . .r..�-<�a...__. ,�:i
I__Eacteria l _ Chemical � _ Petroleum _ Pesticide _ Lead
l . Pe <<<i: : equested by: .
�wner/p;ospective owne;/agent:
4ddress: _ � . Sy.S��
G,
ome P� cne'�• .3 6� eZS6�-
usiness Phone ;:
Name and address oi current owner:
� 7. �imensions or Proposed Structure:
�� ��ridch: Zg
� Deoch: �
�-�— 8. What type (if any, additions, expansions, or
�eplacement is anticipated to the structure or'acility
th2t this sewa�e disposai system is in[ended :o ser�e?
. Prope-y Description: Lot size: /. d'f
. Tax Maan• . f}'- -� b � akri
Parcel�: 3 / - L� 3�
Townshio: . -� .
. Direccions to propercy: State Road n& Road
iames,�tc.
, ii�i ���
9. Water suoply cype:
privace �public ❑ community ❑ spring Q
Are any wells on adjoining property?Yes ❑ No [�
Ii so, identify Iocation:
I0. Type of structure/faciliry: Proposed: DExisting: [
Tyge of dweiling:
House: 0'�vlobile Home: [] Business: L1
Type of business:
Number of Employees:
Number of bedrooms: 3
Garbage Disposal? Yes ❑ No �I
B asement? Yes ❑ No Q'If so, # of basement fixture
�6. Number of occupants or people to be served: �
CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL.
PROPOSED STRUCTURES.
I hereby make application to the PerS011 COunty He3lth Department for a site evaluation foc the on-s
� scwage disposal system for the above described prope�cy. I agree that the contents of this application are true
and represent the maximum facilities to be placed on the property. I understand if the site is altered or the
tcnded use changes, the pecmit shall become invalid. I understand that before an Improvements Permit can
issued, I must present a sucvey plat of the propeRy to th� Haalth Dept. I understand that in the event I have n
delivered a survey plat of the property to the Health Dept. witfiin 60 DAYS after the date of the evaluation ot
the site by the Hcalth Dept., this application shall become void and all fees paid forfeited.
.. n
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Sign ci Owner o� Authorized Agene
� ' .,. s
PLEASE SEE
Tax Map #:
.�
�
Zoning
Applicant: c�G�m � � � a'l..� � � !�
Location: ��75 � �uF� �i �
Subdivision: VC+�K��d9�- A�r� SecUon:
p.. ., �...y
FOR SOIL AREA AND SYSTEM LA�
Pe�e� # 3 I �
Township F ��� �► � C�
Duv'tin Lcv�C, Ltst o n L0 (',t,-� Cul-d�-5c�c O R��t`'`mn Pr i ��
Lot: c�
Improvement Permit
A buildina permit cannot be issued with oniv an Improvement Permit
New V Repair _ Addition _ Type of Structure il N Water Supply � r� �a� `''� 11
# of Occupants ��c+�c # of Bedrooms 3 Other •
Basement? �,Q Basement Fixtures? �J Q
Projected Daily FIow:C��g.p.d. Permit Valid For: � Five Years ❑ No Expiration
Proposed Wastewater System T e: -!.! COl�U t-!L'�1�o � 0.� l� r0.0 o`�!
Pump Required? Yes �No
PermitConditions:�/L'�tC�l` on cc�n-tocN, Kec.� 5�4tic.rn �J�' F�om di�c-rSTan d�tch�
`T.�c�-�. � � r, �� L,., �r. ��v�r�5it�n ditc.� �l�}.�,Id bz. 18" dc.cp �w ide I,.i� o�T `o,T,c �z�jrave.(
Owner or Legal
Authorized State Agent:
, Date: O � v �
oate: � o7%'OC7
The issuance of this permit by the Heaffh 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. Thts 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 wiEh the provisions of the
Laws and Rules for Sewage Treatment and Disposal Systems of the North Carolina Administratfve Code.
Type of Wastewater
COnaciltlo(la �
Faciliry Type: mObi (�. NOM�
Basement? 0 Yes �No
Wastewater Svstem Reauirements
Septic Tank Size: � CjO� gallons
Wastewater Ftow: 3�n(�q•p.d.
New f� Repair DExpansion�
Basernent Fixtures? O Yes No
Pump Tank Size: ��_ gallons
Total Trench Length: "T�� feet Maximum Trench Depth: �_ inches Aggregate Depth:� in.
Maximum Soil Cover: l0 inches Trench Separation: � Feet on Center
Other: I�� W�� � ���P (� �rOM �e.Q'rl�, ��/;-ECM
Permit Expiration Date: o��v� o �
Authorized State Agent: Date:_�'�QD
The type of system pe tted 0 does Q does not di er from the type specified on the application. I accept
the specifications of this pertnit.
Owner/Legal Representative Signatu � ��' �a�� � "^��
?CHD, rev/ 10/12/99
Appiication #:
Tax Map #: 1 4 a
Parcel #: 31�
Person County Health Department
Environmental Health Section
�� at�Ki nS
��ctm m y i�
Appiicant's Name
Authorized State Agent
SITE SKETCH
paK n d c, (�cre.�5 �
Su division/Section/Lot#
L� ��-va
Date
Svstem con:ponents represerrt approximate contours only. Tl:e contractor must flag the system
i ��_�O,
Scale:
PCHD, rev. 10/12/99
PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACH�D PL'AN FOR WELL SITE LAYOUT
Tax Map #: 1��� Parcel # � 1 V
ZoNng -- Township F I�.-t r2 � � e.r
AppUcan� �1'i M u �CI,G� k 1 il J�
i
Locatlon•
Subdivfslon: �a 1� rl a�j G� C�L,� Secdon: ��
� Well Permit
Tvpe of Water Supplv:
V Individuat Community Public
ReQuirements•
Site Approved by :� S o 3t or�
Grouting Apprcy�ed by 5� �o/ s/hc�
Weil Log ��
Weli Tag,,�f�f �� 3� ff� .
Air Vent � s r� sr ea
Hose Bib� c� '�� �
Concrete Slab ✓ S �°�- a�
Well Driller: /"e��"��
Well-Approved By:
Date: 6 � � �
**See Attached Site Sketch*�`
Wells must be 10 feet from property lines.
Weils must be 100 feet from septic systems.
Wells must be at least 25 feet from any buiiding foundation.
Other conditions: Ku-Q wc-�� rnc�x,�mu-m a llu�aa-b IL di��ancc F�orn
�r otic Sv.���M
PCHD, rev. 11/29l99
��, „ �. , Person County Health Departrnent .
��p Enviro�menta! Health Section .
Tax Map #: Paresl #: 3 I�
Zoeing: Township: ��a.� �,�v��
Subdivision• �akr� cl q.� �C(�.S Section: _ Lo� 3 S �
APPticatit SOcw�rhyr n c��J �t n 5 .
LocatiOn' t�S7 S��� � �uS�i v� Ln . 1-0�' a h�� l.k�— c�e-- ��C � �t ��rw,'v� � Y.
�peration Perm it
,
System Type (In Accordance With Table Va): ���������
THlS SYSTEM HAS BEEN INSTALLED IN COMPUANCE WITH APPLlCABLE NORTH
CAROUNA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHO TIO
/o�fl�
Authorized St�t Agent Date
_ �
Person Cdunty iiealth Department
Environmental Health Sectio�n n
Zoning: Townshlp: i'la� F���'
Subdivision: ��� S Section: Lot: 3�
Applicant: �►� � ��"
Location: t S'� s � ►�� � (� .( �.� I�AS��n �n. _�,o�- o�� +h (:u� e�� ��.,�•. �r.
Operation Permit
-
1. LOCATION AND SEPARATION DISTANCES e S
A) System meets .1950 setback requirements ,.,�___.
B) Distance from system to any wells weG Hzt �ti y�f
C) Distance from septic tank to foundation l3'
D) Distance from system to property lines / F�� n� �� ��u �
2. SEPTIC TANK
A) Visually inspect the exterior walls and top of the tank �yeS
B) Visually inspect the interior walls, baffle, tee, filter, riser, lids, air vent,
bottom, and water tight outlet lfes
C) Date of tank manufacture �- a7 '°�'
D) Tank serial number �� /`fa
E) Liquid capacity of tank /ao� gallons
3. SUPPLY LINE TO T�tENCHES
A) Grade �ect�v%^9 (1/8 inch per foot minim m)
B) Material supplx �Ine is constructed from s� � P�c
C) Diameter 3
D) Length � ' /'
E) Distance from tank to drainfield/distribution device 3
4. DISTRIBUTION DEVICE(S)
A) Type /Vft
B) Is Device water tight �pr
C) Distance from the distribution device(s) to the trenches N�
D) Is the device on a level foundation N�
E) ❑oes the device pertorm according to its design specifications �_
F) Record the inlet and outlet elevations N�
5. NITRIFICATION FIELD
A) Trench depth 1 g inches
B) Trench width � inches �
C) Distance between trenches n CPr�� r
D) Number of trenches /
E) Length(s) of trenches � a�', t �a� � �I � ( �S� f � ��
F) Aggregate depth inches
G) Aggregate material and size � S�
H) Record septic tank outlet elevation .5' )• S''
I) Trench grade See d r�(�':"g (< 1/4" per 10')
J) Step downs ' G eS
a. Minimum of 2' of undisturbed earth _„�,_
b. Proper rise over step down � _
c. Solid pipe used �S ,„
d. Elevations of ste downs •��'wc�tecord elevations and show on as built)
See "as built" plan on attached sheet.
PCHD, rev. 10/12/99
�
PERSON COL;N'�Y FNVIRONMENTAL HEALTH
WELL LOG
� • •• ► � ► �,
.
• lF= =��._=`•'-_ -=�:r�= �:_; ;==� '
� � . � � � • �'�1� _ a.i � '� � _ � • !� � ' � '� 11
Subdivision Name:
Drilling Contractor:
L.Ot #_.�-�- �
WELL CONSTRUCTION �
Distance from Nearest Property Line J v Distance from Source of
Pollution ( G �
Total.Dep.th: O Ft. Yield: la GPM Static Water Level a2.r' Ft.
Water Bearing Zones: Depth I�� F[. t3o F� Ft� Ft.
Casing: Depth: From 6 to C�3 Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel
If Steel, does owner approve: Y�s No
� � WeighG Thickness:� '� Height�Aliove Ground: /`�/ 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 Aruiular Space: Yes No
_ .. Method: Pumped . _ Pr�ssure � Poured � . - � . .
Depth: Fr�m O to �. � Ft.
Materials Used: No. Bags Portland Cement � Weight of .1 bag__lbs.
If mixtvie (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 THAT
THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSOv COui1TY HEALTH DEPARTMENT.
' , ,
60 ----
gnature of Contractor Dat�