A40 32202/88f1999 13:49 5971799
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PLANNIN�a AND ZONI�IG
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PLEASE SEE ATTACHED PLAN FOR
M #. V Parcel itl
Tax ap .
Zoning
�
Township F!a-� 12i ucr
Applicant: � �����n�
LocaBon: IS J �' CtFF led, � 1,�5��/tS 4.a G LD� O/) R fj�FDre C(a. l-cl�-S�e
Subdivision: O y�f�4G �rC'S SecGon: Lot: ��
Improvement Permit
A buiidinq permit cannot be issued with oniv an Improvement Permit
New �Repair _ Addition _ Type of Structure 1'11 i� Water Supply �ri ��- W�- ( i
# of Occupants # of Bedrooms � Other •
Basement? Basement Fixtures?
Projeded Daily Fiow:c�o � g.p.d. Permit Valid For: Five Years ❑ No Expiration
Proposed Wastewater System T pe: � (1Utl1�1'onal Grav,ty
Pump Required? Yes �No
Permit �onditions: Kec{� (.JC- f I %(7 � 0/t,�S F�a r�'� ��tr' G�'Ys� /'�S` eC �,�O�i G
S�!'S�Lf'►� 1`(1
Owner or Legal
Authorized State Agent:
nature:
�
Date: � �� ^ � �
Date: o? 1 ' ��
The issuance af this permit'by the Healfh 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 wiih 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 C�� � t� �na� Wastewater Flow: c7� vg.p•d.
Facility Type: Ob I �C �� New 6� Repair DExpansion�
Basement? 0 Yes I�NNo Basernent Fixtures? O Yes No
Wastewater Svstem Requirements
SepticTank Size:,��O� gallons Pump Tank Size: 1��� gallons
Total Trench Length: �i'� feet Maximum Trench Depth: �_ inches Aggregate Depth: o� in.
Maximum Soil Cover: 0 inches Trench Separation: � Feet on Center ��" ���' I�
Other: mGC� Efi,,s O(1 Jll �C. �rlOr 't o��r�.Sf.a ��lt-Fi �O/�
Permit Expiration Date: �vl � �
Authorized State Agent:
Date: C9 a� -�Q
The type of system perr�itted ❑ does Q does not differ from the type specified on the application. I accept
the specifications of this pertnit.
Owner/Legal Representative Signature:
� Date: 6 � � --0 6
?CHD, rev110/12/99
• . ' . ' • �
Application #:
Tax Map #: �
Parcel #• �
Person County Health Department
Environmental Heaith Section
SITE SKETCH .
� ac,�k�'nS C�Kr t dqt R�r�.S 3q
� ppiic nt's Name Su division/Section/Lot#
C� al-�
Authorized State Agent Date
Svstem components represent approxlmate contours only. The contractor must flag the system
� E—�-- I10 ---}�
PCHD, rev. 10/12/99
, Per�son Counfiy Health Department
' Environmentai Health Section
Tax Map #: Parcei #•
r c
Zoning: Township: �loc� ���
Subdivision: �O��v�idq2 t-�Ct(�S Section: Lot: 3�
Applicant• �vv�ru� �-�'ac.�t��wS
Location•
Operation Perm it
System Type (In Accordance With Table Va): �ri����o'�� -�
THIS SYSTEM HAS BEEN INSTALLED IN COMPl1ANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
A ORIZATION.
' -7 .� ��o
Authorized State Agent . Date
Tax Map #: � � � Parcel #: ��` a'
PCHD, rev. 10/12/99
.�
3� To
SflP����
�
Person County Hea(th Department
Environmental Health Section �
Zoning: Township: F� A� ���
Subdivision: �Q 1�r �d�c� ���° � Section: Lot: 3�
,
Applicant: aw-�,,, aw�- �
Location: 1575 R U ��^si'i�.5 ,,.� i.-e� o� �b�� ��-�e-�G
Operation Permit
1. LOCATION AND SEPARATION DISTANCES �S
A) System meets .1950 setback requirements �_
B) Distance from system to any wel(s � rn�n�mK�.
C) Distance from septic tank to foundation 7 � ��w��q
D) Distance from system to property lines as_'T�/� toa �S'�� �
�
2. SEPTIC TANK J
A) Visuaily inspect the exterior wails and top of the tank
B) Visually inspect the interior walis, baffle, tee, filter, riser, lids, air vent,
bottom, and water tight outlet ✓
C) Date of tank manufacture 3�%'4a
D) Tank serial number sT� ��a,
E) Liquid capacity of tank r o 0 o gallons
3. SUPPLY LINE TO TRENCHES
A) Grade �/'a�n (1/8 inch per foot minimum)
B) Material supply li e is constructed from 5' �i �a �C
C) Diameter 3"
D) Length 3 � �
E) Distance from tank to drainfield/distribution device �_
4. DISTRIBUTION DEVICE S)
A) Type 1/ �
B) Is Device water tight N�� -
C) Distance from the distnbu i�device(s) t the trenches /V i�
D) Is the device on a level foundation 1� f�
E) Does the device perform according to its desi n specifications ��
F) Record the inlet and outlet elevations N A
5. NITRIFICATION FIELD
A) Trench depth Zo inches
B) Trench width ,�inches
C) Distance between Venches Q�f•
D) Number of trencfies y , i /
E) Length(s) of trenches 33' �/ �F'. l a5 I> 7 <�0% ���r
F} Agg�egate depth �_ inches '--�
G) Aggregate material and size ��
H) Record septic tank outlet elevation 3�'�
I) Trench grade SE'c ���xu�ia9 (< 1/4" per 10')
J) Step downs
� a. Minimum of 2' of undisturbed earth �
b. Proper rise over step down � es
, a Solid pipe used Qs
d. Elevations of step owns s�� ��'%„ (Record elevations and show on as built)
See "as built" plan on attached sheet.
PCHD, rev. 10/12/99
PERSON COUNTY ENVIRONMENTAL HEALTH
�' � ' ���A�E SEE ATTACHCD PLAN FOR WELL SITE LAYOUT
t
Taz Map #: / 1 �O Parcel # ��
Zoning
Townsh�p FI C�� �� de r
Applicant: �mm � I ,�-�-W" "�' y
LocaUon: �u �� '"" �
A s��i
Subdlvision: ���r�e��` �CrC`S Section: Lot:
Well Permit
Tvpe of Water Supplv: �Individual Community Public
Re4uirements:
Site Approved by
Grouting Approved by � �Q
Well Log
Well Tag
Air Vent
Hose Bib
Concrete Slab
Well Driller: k�•c�v
Well Approved By: �
Date:
%� i�"Oc�
**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: K
la�-ll � c� �
! 0' r� lu..S
�•a�:�
�%G SYs-�ms.
PCHD, rev. 11/29/99
Date: �-3G •� '
Owner: �c�rn.n�
Location/Directions:
PERSON �OUNTY ENVIRONMENTAL HEALTH
r•s
WELL LOG
�
Subdivision Name: ____ (�G. Lot #
Drilling Contractor: � �c
WELL CONSTRUCTION
Distance from Nearest Properry Line 1 v Distance from Source of
Pollution ( G a
Total.Dep.th: � 0 Ft. Yield: /� GPM Static Water Level a..r'' Ft.
Water Bearing Zones: Depth ��Ft. / v Ft� Ft� Ft.
Casing: Dep[h: From 6 to,� � Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel
If Steel, does owner approve: Y�s No
Weight: 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 / Concrete
Annular Space Width Inches
Water in Annular Space: Yes No
_ .. Method: Pumped - Pr�ssure � Poured � . _ . .
Depth: Fr�m O to �, U 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 CERTIFY THAT THE ABOVE INFORM�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTTH REGULATIONS SET
FORTH BY THE PERSON C^v`vi�ITY HEALTH DEPARTMENT.
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