A40 320A�Q�t�, oat�: �_-�`'
/lmourrt Paid• � � ��
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pd � oa.,
a a j�,6 �
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Perso� countv i�teaith oeaaranent
Enviro�tnental Heaittt 9ection
����i _��i[�I:T�•I; � �;tt �x
TaxMao#: 17 �0
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1) P�nit roquested 6y: (pv� er�a�tlProsPective awnerl. ��- �l1 �'n ✓
Home Pt� _ 3 � �l ,�6 -� qdfi,aas — ��,� �i
BtW10�! Pt10�: ' o
Zj Name and address of ciu=s�t owner: ��
oti
3) Proparty O�acrlptloa: I.ot sia� �, a3 r�
D� ta the property (ittcludirtg rnad namea and numbeisk V�� f7.
k �ws
/ � �- S �? A.
� ��5 �3
4) Pcopos�d Usa and Structtue Descrtpttan: answa each af the fono�win9 R�
� ProPcsed 0. E�3s�ng �
b) Stldc Bu�t q Modular q Singla Wtda �. Oouble Wide'8�
n Nwnber of Bedtoamx ��,,, � tdumber d` oc�panb� cc PeoPla to be se�ved
e) Baaement Yea Q No H�ifyes. � of baaemertt �
� t� Garbage Diaposa� Yes q No�
8i 46nsnaionacf Proposad Strucatus: WidttL � Dap� � 6
i�' �PPhr � Pcivate�new a ar �da�n9 �I� Pub�c 4 Can��u�Y 0. sp�hw �.
Acs any waUa on a�oin�ng propert�t Yes 0 No � tt yas, bcattoa
6) Piwss Indic�b Deaiiad Syatem Zype: (syataa�a can be riniasd tn ord�s of Y�' P�)
�ConvenNottal Y�ed Conv�ntional _ At6�rt�w �nnovdiva
Otl�v (sp�:
-s, _ . CLEARLY 3TAKE ALL CARNERS AND UNES OF THE PROP�RTY.
� STAKE THE CORNERS OF ALL P�OPf�BED STRUCTUR�S.
PLEIISE ATTACH SURVEY PtAT OR SITE PUW TO TH13 APPl1CA7iON
��Y �� to the Pe�on Cou�y Health O� icc a a�e evalu�on tor the a�ite sswaqa dispo�l syat�em
ths above�dsscr�ed property. 1 ag�ee that the �ts of this appitc�io� are tn� and rap�ec�t the ma�dau�n faa�es ba
P�eCsd on the pnopeKy. ! undesstand if the s�e ts aRerod ar the i�ended uss ct�anpes. the pem� str� become inw�d. l unde�st�
lhat as app6cant, I am �espons�ie fa� ida�ifying and rt�eran9 pcope�ty 1i�a, cane�a at�d m�g ths si�e ac�bis toc
H�of the Per9on Caurtty Hesrih Oepartrttart to candud their evakt�itana. I tatde�st�nd ihat 1 am re�po�ie f� no�c�8
. mY P��Y ���wetlatuds as desi�0ed bY the Acm�l Corps of F�-
� l
8_��_� v
Owner R�ve . Oa�e
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I��.�a���.�.��.��.Il I�33I��,Il�lh�
Applicant:
Locatiori:
T��x IV1��� � `v P�rc��:�l � • u
S��if,� ri�ri,��ioii �� � � ,
�
Pf,i��,� c Sect�ion Lot �`
-/ Improvement Permit :
Permit Valld for V�Ive Years _, No Eapirallon � � �p��
Type of Facility: 6 �1 New Ac�dition Water Supply _�'� -"�
# of Occupants y�•tGL,Y # of rooms �_ Pmjected Dai y Flo�w � 0 g.p.d.
Proposed Wastewater System: r � � -� Type: �.
Propoaed Repair: �' • ' � � Type: �
_ ./ ' n , . 1 r n _ /� ,
Owner or Legal Repreaentati
Authorized State Agent: �
Date: � -��" ��
Date: ''
The iaeuarice of this permit by the Health Deparhnent in does not guarantea tho iesua.Yce of other permite. It ia the reaponaibillty'of. the
spplicandproperly owner to in eure that all Person County Planning and Zoning and''Building Inspectione requiremente sre mek Thie
Improvement Permit Is aubject to revocation'If the eite plan, plat or the intended nse changes. The Improvernent Permlt is not aRected
by a change ln ownerahlp of the property. Thi� permit was isaued in compliance wltii the provlsione of the North Carolina 'Laws and
Rules for Servage 7ireatment and Dtsposal Systems' (15A NCAC 18A .1900).
�' Authoxization to CoIIstruCt Wa3teWater SySteIri ��teqaired for Building Permit)
* See site pla�t and addittonal attachments (�.
Proposed astewater System: p'✓'� • Type��� G Wastewater Flow 3� g.p.d.
New .� Repair Ex ansion `� Soll LT�►�t: ►�'J g. .d./ ft 2
Type of Facility: � ,� Basement _ Yes �No
,
Wastewater System Requiremeri �a
Tank Size: Septtc Tank: ��.� gal Pump Tank: � gal � Grease Trap: gal
Drainfield: Total Area: �llU sq ft Total Length �� ft
Wtdth �J ft MinLnum Soll Cover: _� in
�tion: Diatribution Box Serial Diatribution
Speciflcatione:
Authorized State Agent:
Pernut Exr
The type of system permitted is
the permit.
Owner/Legal Repreaentative�
Date:
Maaamum Trench Depth �� in
Minirr�um Trench Separation: ! ft
°�
Pre..�sure Manifold�
�� �` i k-�5 {' ��`j r �� v��
— ��� .�.
Dato: C9 �`1 `d �
�ovative �lternative. I accept the specifications of
nata: �i -�l� - � �
_ . - _ --•..s _ -
#
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7E��s�� � ��¢�.g ]f3[��►.Il�IEn.
SITE SSETCH
�o2C�
Name �� �'� K�S Tax Map # � �� Parcel # �
Subdivision��l'� �� Section/Lot##,� ��
��-C ��
A thorized State Agent Date �
System components represent approximate contours only. The contractor must flag the
system �rior to be�;innin� the installation to insure that t�mper �r'ade is maintained.
�\
(�0�
�
,
7s
lo' � pr -
3�� 3a
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���e.�a�- `v''S�i r �z,s �
cit� �S " � �
� � ��s�b S�� G�,�,�,� f
�as��-�� � �
c� ^� e��'
« <�
C� �� � � = 5a ��'��' . .
S �
e
I'
!
t�EMA 43C Simplex ControlPaael
� �� Duct Seal Both
4" X 4" Pxessate Tteatcd Post I Ends Of Tha Ctindmt �O�"te R'ves
Sbped To Shed Water 1Z" Sepuatioa 24" MiitistauY( '"
Electrical Cond�t •. .' . S" Sepuatioa
; Tlu�eaded Gatq Palve ;
.� Uxion • �
. •': • •' 'c • ' . � ' • •. - . :i..0:f%' .
Acce�s Cover• • ' ' 1
6" Cover • ' • • . • ' �.,.�.Portl,utd Coxiczats Gmut
� . .. � r , j �r
I. • � i i � .M . �y . ' t. 1Vii��� • � �
• ��� , r .- - ; . � . . , Zip Corda . � • . ' ppemxigFilled With '
� r.• �P�� Filled With Anti Siphon Hole Tie: SnPP1Y '.
p • . Portland Cemant Criont
Inl�et Fmm Septic TaYtk Po:tlaad Cement GYoat �� � � *�'
d" SCH 40 PPC Pipo "'� � 4ntkt To Dittabutioa
2 SCH40PVC P'
C�ueck .�.Np1oa �°
Valve �Ye Float Wue� � �
' High Watar Alarxn Lav�l , •
�• . (6' SeQazation) � •
,. Hish Leval - Pnmp Oa ; �
� � � Vapas Lock Floaft •' '
.�
• � C �� �Dravvdcwxt �P �A � i �..R,emovable '.:' V �
, ' � ..� � Float Tzae � � �
� � ���
. Law Lavel -Runp Of�' �.
�., ` � � . _
,:.ti � •
�: ' Pnemt Coxurete Tank 4" Cox►cxata ' �' , � �� � �� �
;•; hdatesial Stse h r3S00 PS Block ' I •,�'
��'4,• •, • ,. ' • • • �, . f � • . � �t • • ' � •ti � � '
. � )f�,,� � � � �M
U U� GALLQIY PUlV�.' T1�� �
. 1�
�
Page 2 of 2
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3l �
Pro�le View of Pressure Manifold for Level Site Installation
(not to scale)
Plan View of Pressure Manifold for Level Site Installation
(not to scale)
http://www.deh.enr.state.nc.us/oww/LOSWW/manifolds.htm
8/28/2001
���� �� ���� ��
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IE�.�����.-n �.��¢�.71 ]F3C��.IL�11�.
Applicant:
Location:
T��x Nl��p I � P�rc�el � � �
�. �- •
S�ubci!ivi�s�ion � «,
Ph��se Sec�tio�a'Lot �
J
Operation Permit -
System Type (In Accordance With Table Va): . V
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND A�L NDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORI 1 N.
� � U'2� _ � 2-Z� Z'.
, ,,,` . . . .
ut orized St te Agent Date
Installed By: � l� , ` Date: �� 7��
. �. .� � �as� �P��
_
. _. _ _
_ - . . . _ _ . .� . .
0
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3c �:���CL, _ ._ _- . ..:.�`�f ``_.: :_ .
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PCHD, rev. 07/29/02
� S���'�C �'AN}C aNSPECi]DiV C�iE�9�CLIS� ('iype 11- N G
Tax Ma� # �arce! # dZo System Type Ta le a) '
Owner/A�piicant � �r' �r Subdivision �r�
Address/Location Sec/Pt�ase Lot # 3
State ID/date
Tee and Flter
Baffie
Sealant '
Riser if applicabie)
Tank Ou�et:Seal
Pemnanertt Marker
Pump Tank
Capac
. Water�
Riser
Water
1Sealant
0
Pump
- . . Check Valve/Gate Valve.
_ Anti-si on o e
. . Fioats/Switches .. . _ ...._ . _ ... _.
Alarm visable and audible
Eiectrical Components
Rate (aom)
Approved Pump Model
Blocic Under Pump
Pump Removai Rope/Chain
Distri6ution System
Serial Distribution '
Low Pressure Pipe •
Appr. Pipe Material and Grade �
Valves
t/ Tr•ench Width
Trench. Depth
Trench Lengtt
� Trench Grade
Rocic Death and
�
�_ Dams/Ste downs etc.
1 Pressure Laterais
Hole Spacing
� o e ize
Pipe Sleeve
Tum-ups/Protectors ::
� F�equired Setbacics
� From Wells �. !
�From Property lines
Structures/Basements .: _
� - �tc . es rainage ays
� � � � Surface Waters �
�— Public Water Sup lies
Vertical Cuts >2 ft.
Water Lines
� Vehicle Traffic
Easements/Right of W�
Other
Easements Recorded .
e aerator oni
Comments
ft.
in.
1 l.
pchd rev. 31'13/01
������� ���� ��
� � ��� Jl
I���a-�mm � ���►.7E� I�3L��.Il�
� �UELI; PEItMIT� �
I'I.EASE SEE ATTACHEI) PI.AN FOR WELL SITE LAXOiJT' �
Tax 1ldap #:11J�v Parcel # � � �s�p
: � � � ...�� '�'�.i��.�'�4AlI't�.n.L�l�'1
� �' • ��
��� �� � �i.� - .•� �
�
'Ty�e of Water Su��lv: �/ Individual Comtnunity Public
R�c�uirements:
Site Apptoved by �g� r`� � a
Grouting Ap roved b�_� r q-o a
Well Log t-� 8'(�_ a�
Well T . - . -
Air Veat _
Hose Bib
Coacrete Slab
�+-
Well Approved. Bp:.
. '�°�°5ee Attached Site Sketch'�
Wells must be 10 feet from property lines. �
WeDs must be 100 feet from septic systems.
Wells must be at least 25 feet from any bu�d'mg fouadation.
Other conditions:
�, �p � �r,,� �jM�p,Q,% 11iui��1/'�t�.tiM -
�r\� �%�i �,�,�R�� i�i(�� PC.fID, rev. 09/07/01
oZ�� �`'�- �'�'�`�� ��*
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�� �L/ � �� � �
���a-�������.� ��.�.���.
Owner: �
Location:
D�o� OD � � �
0 0 ��g �� �G �'H � W G II �G
o ° �6U[�1 g -- / 7-02
Well Log
Tax Map f'} � Parcel # �
Subdivision: `� Lot #
Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from Septic System {Minimum 60 feet)
Tota1 Depth: I� o ft Yield: GPM Static Water Level: Z� ft
Water Bearing Zones: Depth p jft ft ft ft
Casing:
Depth: From �_ to � ft. Diameter: (� y in
Type: Galvanized Steel � �-
Weight: Thickness: . i�� Height above Ground: / S in
Drive Shoe: _�Yes No Any problems encountered while setting casing? Yes ✓�io
If "yes" give reason:
Grout: /
Neat: SandlCement ✓ Concrete GraveUCement
Ann.ular Space Width inches " Water in Annular Space Yes No
Method of Grout: Pumped Pressure Poured Depth to Ft
Materials Used:
No. Bags Portland cement Weight of 1 Bag Pounds
If mixture (sand, gravel, cuttings) - Ratio to
ID plates: Yes _ No 4 x 4 slab _ Yes _ No
Drilling Log , , - Location Drawing
From To Formation
7 0v
� ���`�•
/?-o
r���
� ��-
yb�
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I hereby certify that the above information is cairect and that this well was constructed in accordance with regulations
set forth by the Person County Health Dep ent.
Signature of Contractor ID#_��� Date Q-�7�p2
PCHD rev 01/16/02
�
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