A40 321.�• �=.Amount paid ��� �'�
. Rece.ipt i ' o t ,
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?er.s:r� G��urry �-�aith C�;:' �� ���
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,�:..,:� � '� � � '_ . :.�;� ���;���i5ecvi'c`es�Requ�fed "'_ -��
K.;
_ Imprevements Permit.(Established/Recocded Lot) _ Reinspection of Existing S
�mtyovements Pecmit (Unreco�ded Lot) _ Repair/Replace existing Se
_ improvemeats Permit (Mobilc Home Replace) �Permit foc �Iew Well
_ Improvements Permit (Addition) _ Replace Existing Well
i T � Fi? 3 t t �.. • . . ...... ,
�� " _� _-�; Y.,�,>�' ��' �"�; �i;Yatec�ample�ti'o`be CollecEed *~ X' r`:::
_ _ .a. _ .....r. .�:,
. ...,.._ .. ._....... . ... .. _.. ,. . ...�........._ .- ---......__......._ _._... ._.. ....._.:..
_ B acteria ( _ Chemical I _ Petroleum _ Pesticide
. Per�;�it :equested by: .
�vner/p;ospective owne:/agen
�ddress: . _ .��,�5.
ome P� cne `: 3<<i as'��—
. . . ; i.:
tem (Loan Closing)
ic System
_ 7. Dimensions or Proposed Structure:
4 Wicch: z8
? De�ch: � � ,
_ Lead
�'"� �'�S S. What type (if any, additions, expansions, or
re�I2cement is anticipated to the structure or'acility
that this se�va�e ciisposal system is intended :o secve?
usiness Phone �:
, Name and address of.current owner: 9. Water suoply t}•pe:
SA m E private t`��. public ❑ community ❑ spring C
Are any wells on adjoining property?Yes ❑ No Q
If so, identify location:
. Prope: �y Description: Lot size: 1� 4� ��
. Tax Man�: . � N e ���c�
Parcel�: .3-z l � �
Township:_ �.�R�
. Directions to property: State Road �& Road
tames,�tc. ,/
_ /I �l �1� i�%-
10. Type of structure/facility: Proposed: �Existing: �
T'ype of dwelling:
House: �Mobile Home: ❑ Business: C!
Type of business:
Number of Employees:
Number of bedrooms: �_
Garbage Disposal? Yes ❑ No �I
Basement? Yes ❑ No�f so, n of basement fixture
�6. Number of occupants or people to be secved: � �
CLEARLY STAKE ALL CORNERS OE THE PROPERTY AND THE CORrIERS OF ALL.
PROPOSED STRUCTURES.
' I hereby make application to the PerS0i1 COutlty He2lth Department for a site evaluation foc the on-s
sewage disposal system foc the above dcseribed pcop�cty. I agrec that the contents of this application are ttue
and represent the maximum facilities to be placed on the property. I understand if the site is alterod ar the
intended use changes, [he permit shall become i�valid. I undecstand that before an Improvements Permit can
sued, I must present a survey plat of the property to the Health Dept. I uaderstand that in the event I have n
delivered a survey plac of thc property to the Health Dept. wicizin 60 DAYS after thc date of the evaluation oi
the site by the Health Dept., this application shall become void and all fees paid focfeited.
0
z
Sig�c� Owncr or Authorized Agcnc
Application Date: �i-, �O- (3 ��� S� ������ Tax Map: �� Q
Amount Paid: __��y(f� ._..; � • �,�- � � ���� Parcel#c 3 � I
Receipt #: � L—
.�".�rawaa•�aaana�and.s.� ��e,.aIl�,�aa.
Services
I] Improvement Permit (Site Cvaluation)
$200.00/$300.G0 (if> 600 gpd)
L YIohile Home Reptacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement/Repair)
$300.00/$200.00/$'15.00
for Services
� Constr�iction Authorization
(Fee is depender.t or. the type of
0 Permit Rev�sion
Repair of E�isting Septic System
` Application: No Chazge/ CA $150.00 or $300.00
1) Applicant Information:
Name: �1 G--ilc�-�.t.._ �pc� �' `
Address: _�'�� �{s� ► n 1-c.._� e
�.2��bor� �lL �-1`�"1�1
2) Name and address of current owner (if different than applicant):
Name:
Address:
Phone (home): C. 3�� �� o�Ct - �/ a� o�
(work/cell):
Phane:
3) Property Description: Lot Size: _ Subdivision: �Lot #:
Address and/or directions to Property: C-�o c��n 1.�ur dlc fn< <►s �d , i�r n'r' ��h�-
Ot1�� �F 0.�• Th,cn .�-t�n (' :�,11�i- c�nk� "D�-tS}-in 1-G-nc -'�30 � s o r1
❑ yes C�3�no �Does the site contain any jurisdictional wetlands? � +�L r;�h+
�❑ yes 1��3'n�o Does the site contain any existing wastewater systems?
❑ yEs �no Is any wastewater going to be generated on the site other tt�a�i domestic sewage?
❑ yes �� �Ts thz site subject to approval by any other public agency?
O yes L�no Are ther� any easements or right of ways on this propert�?
(if `yes' is checked, please prot�ide supgorting documentatien)
4) p�sed LTse and Type of Structure:
�Re ential �
e�'N w Single Fami(y Residence Maximum number of bedronms: _� � �
❑ Expansion of Existing System If expansion: Cunent number of bedr�oons.
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes �no With plumbing fixtures'? ❑ yes O no
❑Non-Residential
Type of business:
ivlaximum number oiempioyees:
Total Square footzge of Building:
Maxim um number of seats:
5) Wat�r Supply: C1 New well L7Existing Wel! ❑ Community Well ❑ Fublic Water O Spring _�
rlre there any existing welts, springs, or existing waterlines on th;s property7 ❑ yes � no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
� Conventior�al ❑ Accepted 0 Innovative ❑ Alternative ❑ Other ❑ Any
1 cert� that the ifzf'or.ntaiion pf•ovided abnve is contplete and corf•ect. I also understand that if the infvrmation provided is
inaccurate, ot- if the site is subsequently altererl, or t1Te ir:tende�� use chunges, nll perm.its and approvals shall be im�alid.
�s
5ignature (Owner/ Legal Representative*)
* Supporting documentation required.
�-1 t�-�3
Date
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
�EASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM
Tax Map #: TI `' � Parcel # �'
Zoning Townsh(p /—�CY.'� � ��-�
Applicant: C�m m haW 1/ls
Locatlon: ��7� +02 f-{u FF �d � Ot,�t i n� Lcc n c. L�t on �art Cu 1-dc -Sa c
Subdivision: l.�Kr� d�fC- 1� CiC.� Section: Lot: cJ �
Improvement Permit
A buildina permit cannot be issued with onlv an Improvement Permit
New �Repair _ Addition _ Type of Structure � Water Suppl�,_['t�-�- W C I�
# of Occupants `1 # of Bedrooms � Other •
Basement? Ll _�—Basement Fixtures . ��
Projected Daily Flow: 3�g.p.d. Permit Valid For: [[�"Five Years ❑ No Expiration
Proposed Wastewater System Ty� :.LL Car1 U C(1'�l ('�l10. I rCi V 1�
Pump Required? Yes ✓ No
Permit Condi#ions:,
e.
Owner or Legal
Authorized State Agent:
� M DL� D�F _ IDG� -lVi n9 Gi.rc� �
Q ly1 rn !�n'n t.�m
� la u-t s�cm � ti�.�� �NS vt�r f"y� p���°�
�� �
Date: /�t- I(- o n l�/l,s� llu.fi o''
Date: � ' �
The issuance of this permi�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 s'rte 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.
Authorizaiion To Construct Wastewater Svstem (Required for Buildina Permit)
Type of Wastewater System Canvcn���on� / Wastewater F1ow: ,,,_ �oC79.p.d.
Facility Type:,�OD) � �0 New �Repair OExpansion ❑�
Basement? CI Yes o Basement Fixtures? a Yes CsYNo
Wastewater Svstem Reauirements
�' Far Rtpair iF .�
Septic Tank Size: ��� gallons Pump Tank Size: ���_� 9allons nlecc.SSu�r
Total Trench Length: ,�_ feet Maximum T�ench Depth:�_ inches Aggregate Depth:� in.
Maximum Soil Cover: �� inches Trench Separation: � Feet on Center
Other:,�CE�I.c�C�( f l0 �� DI u�S F�om '�iCPt�G �-rrtG� .
Permit Expiration Date: l�`o� �— ODJ�
Authorized State Agent: Date:�f '�D
The type of system pe itted ❑ does Q does not differ from the type specified on the application.
the specificatians of this permit
Owner/Legal Representative Signature: � Date: �-`" ,.
I accept
PCHD, rev/ 10/12/99
.' ,
Application #:
Tax Map #: 9�
Parcel #: 3a �
Person County Health Department
Environmentai Health Section
SITE SKETCH .
�# ,,�mmy �{cic�k � nS Oa Kri d�rt �} c. ��-s 3 8
Applica t's Name 5ub vision/Section/Lot#
(�al-oo
Authorized State Agent Date
System components represent approxlmate contours anly. Th contractor must,flag the system
nrior to be�inning the installation to insure tlrat proper grade ' maintained
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PCHD, rev. 90J12/99
.. � Person County Health Departrnent .
" (,� Environmental Heaith Section •3� I
• Tax Map #: t� �Q Parasi �: �
Zoeing: � Townshtp: �%r.�' � i V e�
Subdhristom �Gl�l'� �_ �'7G�-� 8ection: I-o� � U
Appqcari� S m/� � l r �
Loqtlon: l �'S S S r /1 �- �- � T o Y► � �' C�,,Q _ � — ��
Qpe�ration �Permit �
� � � � ��
�
System Type (in Accordance With Tabie Va):
THIS SYSTEM HAS BEEN INSTALLED IN COMPUANCE WITH APPUCABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE 'fkEATMENT AND DISPOSAL;
.AND ALL CONDtT10NS OF TlalE IMPR�VEMENT PERMIT AND CONSTRUCTION
AUTHORIZATION.
II a�/�O
Auth ' State Agerrt Date
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PCHD, rev.10/1?199
Person County Health Department
Environmental Health Section
Zoning: Township: i� /�,� �/'�c � ,
Subdivision: t� C� Section: Lot: �_
Applicant: S� h'
Location: �s" 7 S iQ i� L��, g� � a�' G� �_
��
Operation Permit
1. LOCATION AND SEPARATtON DISTANCES
A) System meets .1950 setback requirements �
B) Distance fram system to any wells joo `
C) Distance from septic tank to foundation 5�/ S�
D) Distance from system to property lines �P /�,�e
2. SEPTIC TANK
A) Visually inspect the exterior walls and top of the tank _�
B) VisuaUy inspect the interior walls, baffle, tee, filter, riser, lids, air vent,
bottom, and water tight outlet �
C) Date of tank manufacture 5� o� �
D) Tank serial number 7F� g9
E) Liquid capacity of tank gallons
3. SUPPLY LINE TO TRENCHES
A) Grade ��_ (1/8 inch per foot minimum
B) Material suppl I� e is coristructed from 8 �'�
C} Diameter ` -
D) Length � � � /1
E) Distance from tank to drainfield/distribution device 7T
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 �o mches �
B) Trench width inches �
� C) Distance between trenches 4i7 C
D) Number of trenches , � /
E) Length(s) of trenches �` �D � �i�� �/O�U� 78 .= �% y�
F) Aggregate depth r inches
G) Aggregate material and size ��%
H) Record septic tank outle elevation a�%a ��
I) Trench grade �c� �� (< 1/4" per 10')
J) Step downs
a. Minimum of 2' of undisturbed earth
b. Proper rise over step down -P�
c. Solid pipe used� \�$ ��{��;
d. Elevations of step doivns 5�^ (Record e�vations and show on as built)
See "as built" plan on attached sheef.
,�
� PCHD, rev. 10/12/99
PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Taz Map #: f'f -7 v Parcel #��
Zoning
Applicant: ��� I '�� ( n�
LocaUon• ��'�r �`�
Subdivision: r ( Cr� Section:
�pe of Water SupplY:
Requirements•
Site Approved by �
Grouting Approved by
Well Log
Well Tag f
Air Vent � �2S �
Hose Bib /a
Concrete Slab � /a .
Well Driller: a�"n�%��
Well Approved By:
Township �/�-� R� �er
Well Permit
Individual ,
��' /� i5/�
�� �
d0
�
oa
Lot: �
Community Public
Date: a
**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.
Other conditions:
C� O
O�u.�S Fnc m Stpt,iG /i re�-�
c -- , oF .O� t,�� - -
PCHD, rev. 11/29/99
Date: y-� '
Owner.
Location/Direction :
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
�
;a
SR# ' � � �
Subdivision Name: Lot # 3� —
Drilling Contractor: � T–'�c
� WELI, CONSTRUC'I'ION
Distance from Nearest Properry Line I v Distance from Source of
Pollution ( G � �
Total.Dep.th: O Ft. Yield: GPM Static Water Level a.5—' Ft.
Water Bearing Zones: Depth,��_Ft. / YO Fc. Fc. �t.
Casing: Depth: From 6 to,�`�_Ft. Diameter: Inches
TYPE: Steel � Galvanized Ste�l
If Steel, does owner approve: Y�s No
� � Weigh� Thickness:� '� Height�Above Ground: /�/ Inches
Drive Shoe: Yes ✓ No . � �
Were Problems Encountered in Setting the Casing? Yes No � �
If "yes" give reason:
Grout: Type: Neat Sand/Cement / Coricrete •
Annular Space Width � Inches
Water in Armular Space: Yes No
_ .. Me.thod: Pumped . . Pr�ssure � Poured � . . .
Depth: Fr�m O to �2 d 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 CERTTFY THAT THE ABOVE INFORM�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSO� C�uiJTY HEALTH DEPARTMENT.
Signaturc of Contractor Datc