A40 319Application Date: ������3
Amount Paid:
Receipt #:
Tax Map #: � �O
Parcel #: 3 ( �
���_S� I��I�.���
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� a�_�as-�.�ca�--TM^ �aa�mIl ��m�Il.��a
APPLICATION FOR SERVICES
IF THE If�lFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED
CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMEPIT PERMIT AfVD AUTHORIZATION TO
CONSTRUCT SHAL� BECOME INVALID.
1 Permit re uested b Ownerla ent/ ros ective owner :,,� h�c,� o ns u c;SC � j�cSu� u /�
") 4 Y� � 9 p P ) 1f � f-�ur �,� �, C� y/"
Home Phone(�3�) � Soy—+.f�S7��6 Address:
Business Phone: _, ____ .
2) Name and address of.current owner: �O�S-6Z�n C�a`/�A/
3) Property Description: Lot size: ��-� Township: Subdivision: Qa�H �ot # 3�
Directions to the property (Including road names and numbers):
4) Proposed Use an Structure Description: answer each of the following questions:
a) Proposed , Exisfing _, Type of Structure:�4 �.�c.�'1 Width: .Z�n Depth:�_
b) Number of Bedrooms: �_ Number of occJpants or peopie�to be served: _�
c) Basement: Yes , No ,�, Will there be plumbing in the basement?�
d) Garbage Disposal: Yes , No,�
5) Water Supply Type: Private ✓(new _ or existing�✓ , Public . Community_, Spring _
, Are any wells on adjoining property? Yes_ No _ If yes, please indicate a�proximate location on the
site plan.
6) Does your property contain previously identified jurisdictional weilands? Yes_ tdo_
PLEASE NOTE THE FOLLOWIfVG:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED.
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AiV EVALUATION BY THE HEALTH DEPA►RTMENT
STAFF.
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal
system for. the above-described property. 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 intended use changes, the permit shall
�'- %o2-(S�
Date
PCHD, rev. 06/27/02
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�erso� Courrtv Hesith Deaartm�c�t
Enviro�mer�tai HeaWt 3ection
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Tax Mao �k �� 5C v
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IF THE INFORMATION IN THE APPUCATION FaR •AN IMPROVEAAENT PERMIT 13 FAL91Fi�. C�WNGED, OR THE SiTE IS
ALTERED. THEN'THE 1MPROYEi111E�1'T PERMIT AND AUTHORi7AT10N TO CONSTRUCT SHALL BECOME INVALID.
1) P�s�mlt requsat�ad by: {own.�gontiproap�cttw owne�: S R/h Mi A u✓ '� �w s
• Homs Pt�on� 3 L�f � S� 2 � Adst�� S u/r a�,+�j , c� i s,� ,U
Bt�tess Phone: " d`+' o k!.' � s .� C>:z 9 3"� J
Z� Nam� atui add�s+s of cumertt ownK: S�'� F
3) Ps+op�rty ��scriptio� I.oc � ���S Ta� �, R•
� Lo the propedy pncluding �nad r�amea and ruunba�sx � v� l� � C3 �
4) Ptopos�d Us� and Struct�tc� Descrlption: answe� esd� affhe fanowi�W que�oc�a:
� ��� � Q
b) Stidc Bu� q Modutar 0. Shqie Wide 0.�+� Wid� 0�
� Number ot Bedroa�rs� ,�, � NtuN�ec af ocaupanb� or peopla to be senre� `�
e) Haaema�t Yea q No Q�if yes. � of basert�art �dttcex
' f� Ga�tiaQe Disposa� Y�a q No 0�
� qin�ioctisaf F'toposed Structuta: Vllidttt: �� pepft� � a
aI ��+PPhI �►P� Pdvab 0'�new a ac eodatlnA �. PubRc 4 Comn�u�Y o. sp��q 0.
Aro atry weUs oe a�oining p�opat�? Yes � No 0 tt yes, focation
6j PM�s� Indicab D�sii�d Sysmm TYAs: (syai�na can be �nlad in oc� of Y� P�l
✓Canv�cttl�o�t � Canv�nttatal _, A�n�iw �nnovativ�
__ O�lw (sp�d�yjt
��EARLY. STAKE ALL C�R�IEFtg ANC 11NES OF THE PROP�RTY.
STAKE THE CORNEii�S OF ALL PROP08ED STRUCTURFS.
P�EA3E ATTACtI SURVEY PU1T OR SiTE PUW TO Tti�S APPUCATtON
I ttecebY make � to lt� Person Couc�iy Health Dapactment 1br a a�s avakt�tlon � the on-sits sewaqa dispo�l sYst�►
tha above�desa�ed properiy. l aqree that the cAnLenb of this applicatfon acs ftua and reQ�art the �mo�u� �- to
piscsd on tha proQecty. 1 uada�tand if the s�e ls alt�ced ar ths intanded t� dtanpes. ttte pent�it sttaa becans invaild. l tmde�
ttt�t as apQBawrt, 1 am �+espoin�ie tor tdaW�g and ma�icin9 P�'�Y �, �mecs and mald�g ths sibe a�s �
pesso�utd of the Person CcuMy Hea�h Oepartrnent bo canduct tl�ir evdimttotu. l ta�ecatand Ihat 1 am t� ��8
Hea�t� ent ff rtry ptopecty �s a�ry wetlat�da aa desi�na�ed bY the Army Ca�Ps of E�p�.
� ��� 10 -- ►�-- o�
_ o� L.sqal Reprsasnt�t[ve . oame
�•�� �T.
� •/' � � � � ��:
- ( (�) l � I �
�: �._, .: ._. ., . ._,. . - .: , _ � �: � _ _ � , � ..
a� � #�. g� # 3
�xisting Seowage Spstem Re�ort For. ob�e I�ome Replac�me�t �C r
. - -�ddition Type: � � �f��'`
�.teqnestes: � Q' b L. C- �Q Yt Home Phone# .y� �" l�/02'�
Osiganal l'eamit Located: S
Septic Spstem Desi�me� For. �Residential
�usirtess #
�i�0'
Water Snpply: �`C `' 1
Bnsinesa Othet
# Beairaoms l�' ._ # Employees ��s �
� �0 � c� q,�� '� �
Spetesn Tppe: P/1/�� '�'ank Size: _ 1Vitrification Y�ine:
f• � .
. I�ate Installed: �' ��`� � Ceatified Operator Required: �l� C7 �
C�n site wastewater �is�osal system sfiows no �suai sigas of malfuascti�on on .��j��
� �j� ���_ . r-��C� � �ore.�
I'ermission is granted to• ol�n �'�1Y`l.t.!�'� �
. , �
Com,ments• �
' t3,-� �
�*+�+r�nmeutal Health Sper.ialast ��� Date: �
,� '
- - �'���E S�� �
TaX lIIaQ iR /
zoniag
�►PP�C R �'
l.oatlon: i � % S
��#�St3R1 Gt3l9iV� ��1V1R�P111AE�ITAL i�E�1i:Tii
�/ s �
�� 31�1 �
Tow�tdp ,�/�v X t�OrU . ..
Suhdtvbio� � V' ,e G%�-°i � � 3 �
� Improvement Perrnii � ,
� � A buildiny,_�ennit cannot be issued with aniv an imarovement P�nnit
• New � Re�aic Addiioct Type o( S6vchue � F� Vltater Supply UI e I I .
# of Oa��antss #•af Bedraoms � Other
8asemerrt'1 J�f _ Basemerrt Fodures? �
Projec6ed Oa�Y Fiow: T�.v 9.{�.d Permit Valid Fot: �(
Praposed Y� Sysflem Typ� C.o rf v P.�-�'i �
Pump Required?' Yes �_No
Ptopased Repair : n u m� G� n v P�i f'o na �
Permit Cand�ions: ,�'ee s4s � 'r+;K -�-nn•
/ .�
I�LS _ �t�i�1 �.
0 No �piratlon
s��o k na�-f'o +, � (� �
Qi �i I� Q�' Drn/J�r � d(Y�tc
0
�n-� ��Bylvu.r
Owner or Legal Repr�re - - �te:%�% "a�.�"�;
Autlwrized State Agert� Date: ��- ��l UD
The issuance �af this perrnit by the Heatttt Departme.nt in na way gtraraMees the issuance of atlter p�is. 'The perc�ui
holder is respans�le for d�edong with appropriate goveming badies In rt�eeUng theic requiremeMs. This sita is
subject bo revocaticn if the stba plan, Plat, or the itrt�ettded use changes. The ImQrovement Per:nit si�ail rrot be
affectecf !sy a cl�ange in ovme�stilp cf the site. This permit ts subJ�ct bo campl'wnce vYith tha provisions of the
Laws arid Rules for Sewage Treatrne�t aad �iaposal Sys�w cf the North Caeniina Adminlstrative Code. .
Type cf Wastavvater Sj�stem (�n V'O.r�.f c��•t�t Was�water Ficw: _���g.p.d.
Fac�fiy Type: 'a�', S, �� �' . New� Repau' OExpansian ❑
8asemea�t? 0 Yes No Basem�t fadtuea? 0 Yeaj�CNo
Wastevratar Syatem Reauiremenis ' ' - • '
..S�T��: ll�b � ��T��: �oa � � .�T l�� ��i�
Total Ttendt Length: ��� fe� Maximum Trend� De�tk 'L 7 indt� Aggcegabe Deptt�� it�
Maximum Soii Caver: � in�es Treru� Separa�On:
� on,er_ C�n /acl c� v ��oh ntie n.T�c /�
Permii Exp�ation Date: �
„ . - r = • • ��11�l�L'`L�
D 5`�
Feet cn C�ter
�'t�` r �'U2�l � Sl �P , `oCa� �
_ d�; • f•�- 29 d-p •
pe o sys perm�tted oes do'es not. dtfifer from the type specified on the appiication. I ac�pt
the specificattans of this parmi�
.. OwnedLegal f�reser�tive Sl Dz�e• D/ •
• PC�-1D, rev. 91/18198
. __--.. _.. _ .__...--�--._...___. .... .. _.- -
��r��n Caunty 4iealth. Department
Esa�ronmenfiai Heslth Section Tax��ap #: �b
_ . . � � Parcaai �: � 3 f q
� S�'i'� Sl4ETCt� � _ . . _.
( �A GJ�iks • �Ol, �Vi1 Q � S � a � .3�
�p s Name Subdhrision/Se oNLat#
S U�v � a 2�t oo .
Autho�lZed Aent ��
,sy�em ca�One�� x�rese�rt appnour�� cnatoras o�rly. Tbe cnr�a�ar mu�t flag the syslmt
prior to b� tlire in�alladon to �e that P�'+oPa' 1�'ade is mabrtai�ed
t.w-
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V �/ � Cc`�� �viron�e�'4
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a��� lqb�� y�,e�� �
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s�: � �� �. �� --
S°�Pl� c. ��EPfl� R lat 3 .
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Person County Health Department
�Environmental Health Section
Tax Map #: � �� Parcel #• �� �
Zoning: Township: ' �`v )C� iC�
Subdivision: � �� � � Section: Lot: . ��o
Applicant• �`�'� � �
5 � �� � � > /o� � � C �,,.��� ��
Locat�on: 7
Operation Permit
System Type (In Accordance With Table Va): _ —��
THIS SYSTEM HAS BEEN INSTALLED IN COMPLlANCE WITH APPLICABLE NORTH
CAROLlNA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZATION. _ r
v� t� � I��61
Autho ' ec! State Agent Date
�;,.._ i = �a'
�'"'a� 77�
L�,,,� 3 = g,5 j
t;�...y=l�Y�
:�. 3 _ � o / �
�v=l0 y�
Ne
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Tax Map #: Parcel #:
/
J
/�
PCHD, rev. 10/12/99
Person County Hea(th Departrnent �
Environmental Heaith Secfion
Zoning: Township: _�4 �C G��C�
Subdivision• K% c Sectiom �fl� �
Appilcant: 5 a .
Locatiort• � � `� " ��
Operation Permit
1. LOCATION AND�SEPARATiON DISTANCES
A) System meets .1950 set�ack requiremen � �
s em to an wells g� �
B) Distance from yst Y - I
C) Distance from septic tank to foundation ��._,
D) Distance from system to prAperty lines �o ��
2. SEPTIC TANK
A) Vsually inspect the exterior walis and top of the tank '�
B Visuall inspect the interior walls, baffle, tee, fiiter, riser, ids, air vent,
) Y
bottom, and water tight outlet � �
C} Date of fiank manufacture c a- aa-a�a
D) Tank serial number �Tg �N �-
E) Liquid capacity of tank lhB r� 9alians
3. SUPPLY LiNE TO TRENCHES
A) Grade (1/8 inch per foot minimum)
B) Material supply line is canstructed from
C) Diameter
D) Length
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 levei foundation _
E) �oes the device perfortn according to its design specifications
� Recard the iniet and outlet elevations
5.
NITRIFICATION FIELD
A} Trench depth mches
B) Trench width inches / �
C) Distance between trencties ' n
D) Number of trenches /
E� Length(s) of trenches "
'� Aggregate depth 1� inches s
G) Aggregate material and size _
H) Record septic tank oudet evaiion R' T
() Trench grade (<_ 1/4' per 10')
. J) Step dovms
a. Minimum of 2' of undisturbed earth
b. Proper rise over step dovim
c. Sofid ipe used � i'av� +
d. Efeva ons of step d wns �'� (Record elev ons and
show on as built)
See "as built" plan on attached sheet.
PCHD, rev. 10/12/99
PEi�SON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN F�R WEi_L SRE {-p►YOUi'
Tax YaP �k � 'CO Pttsd i � � �
�9
• T�at�P i� �o ro
JL} Yh � ��/Ca �+/��L� S � '
APP� _.�--- --r .
� S � .s- - � sf h a.�- .
1 e / .. .! . ' %:; � .�n � 'L
� . Y/✓l� �Z�s �DIC ��
Tvae of Water Supalv:
�.
Reauiremen�s:
W@�� P9r117�t ' '
�ndividual Community . Public .�� I
� I �vi�'71hF� a�i
�
. Site ApProved by �� l�S ���9 �
Grouting Approvedby ✓ �' �
Well Log t/
Weil Ta9��n �S= o� .
Air Vent �/o �- s-o/
Hose Bib - -o/
Concrefie Slab -- -0/
R
. � (.�h' aC
��� j� �►- 1�rel( ���
_ �jCc,,�idn
�
Weil Dril[er: �r.� r n � . -
Well Approved By: ��� ,_�____ Dat,e: �� -� S` � �
�`*See attacfi�d Site Skefich**
�
We11s must be 10 fee# from propecty lines. l -� . .
WeUs must be� from septic systems. 60 �' r. s-er�i c�. S=� s��.•, y►�, � h i Y►,, u�
Wells must be at least 25 feet from arry building foundation. �.. � : .
Other con
ditions: �h�a. C� �h V� i�—oh hti� n�a ���R �� � r �t/� �� �' � .
�i -�-e L����-7-i a ►J �
�
�
�
r,
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PCH�, rev. 1�129/99
Barnette Well Drilling Inc
�i
336 598 9275 �3/12101 �5:26P P.�Q1
P�RSON COUN?Y ENVIBOtZMENTAL H�ALTB
WELL LOG
�
�
Owner, qMtil�_ �1�1 L SR# ' � -
�_ .,_ . .
LocationJDirections:
Subdiv�sion Name_
Drillzng Contractor:
Lot #
� WELL CONSTRUCTION �
Distance from Nearest Prnperry Line � cy Distanee from Souree of
Pollution ( � a
Total_Dep.th: � Ft. Yield: '30 GPM Static Water i,eve� �?.r" Ft,
Water Bearing Zones: Depth '�7U Ft. "' F� Ft� ��
C�sing: Depth: �rom b to Fc. Diamet�er: Tnches
TY1'E: Steel � Galvanized Sceel
Yf �teel, does owner approve: X+�s� No
� WeighG � � Thiekness:.�.� Height�Above Ground: /�1 Inches
1?rive Shoe: Xes ✓ No .
l�ere Problems Encoimtered in Setting the Casing? Yes No �
If "yes" give rcason:.
Grout Type: Neat Sand/Cement / Concrece
Annular Space Width � Ynches
Water in Annular Space: Yes No
. .. Method: Pumped Presswre � Poured � � • �
Depth: From O to �� O �L
Macerials Used: No. Bags Portland Cement - Weig�t of .I bag_lbs.
� mixture (sand, gravel, cutunas) - Ratio: to
YD Plates: Yes � No � �
�4x4slab Xes i No
I HERE$X C�R'T7�Y'Z'HAT THE A,BOVE �OkMATION IS CORRECT AND THAT
7I�IS WELL WAS CONSTRUCTED II�1 ACCORDANCE WTTH REGULATIONS SET
�ORTH $Y�THE PERS�� COvi1'I'Y HEALTH DEPARTMENt'.
- . .
(__.
S" natutc of Contractor ���