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IF THE INFORIIAATION !N THE APPUCATION FOR �AN IMP4tOVE11AENT PERMiT 13 FAL91R�. CNANGED OR THE SiTE !S
ALTER�D. TNEi�!'THE 1MPROVE�VIEi�1T PERMR ANO AIJTHORTZATION TO CONSTRUCT SHALL BECOME INVALID.
�� P.mac r+syws�ea by: �ovmerhe��pr�pac�v. ownsrl: ft �► M Y IJA u�; n� s
Hortfs Pt�on� 3 G 4 s.f C'Y . qd,� ,� s�" a R o�� �� c. � S!?�,
B1�10� PhOt1e' � e� 6� e�P � /►' c� f'73
Z� Name at�d addrea: of currarrt awner. . S��+ E
s� Pr�op�rty o�s«tptio� t.oc s� ��98 Ta�t� �. R• o F R p,
o� ta �,e �► �� �ad r� and �k i� F
4) PtoQos�d Us� and Struclttre Deseriptlan: aitawa eaci� af the fa0�owinq queationa:
� P�oPo�ed 4�E�q Q
b) Sli�cdc Bu�t q Modutar �. Si�nnpie VVfde 0. Da�ble Wtde tD/
� Number ot 8edroocrwx ��- „ c� Number af occtQanb� o� peapis to be secved: 'f
a) Basem�t Yea q No atf yea, � of baasme��t �tuex
. f� Gari�age Oisposa� Yes Q No �
� Qh�sions cf Pt+oposed Strudure: VVidtt�: � 8� Oepdtr �� ,
�1 Wabc Su�Ph1 �: Prfirais �( �w a or eodsUnO Di� Pub9e 4 Camxa�tY o. Sp�+Q 0.
Ars any waqa on a�oWng pc�ert�? Yes 6'�l0 � It yes„ locatlon
6� Plas� Indtcat� O�siisd SYstsm 'iype: (sys�ms can ba r�c�fo�d in ocd�+c of Y� P�l
�Coavecttlonal Yodified Com�tlonal _ Atbma� �nnovatiw
Ot1w (SQ�d[yj:
CLEARl.Y 3TAKE ALL CORNERS ANO UNES OF THE PROP�RRTIf.
STAKE THE CORNERS OF ALL PROP08ED STRUCTURES.
PLEASE ATTACH SURVEY PU1T OR SRE PUW TO Tii{S AP4UCATION
I hersby rt�ake app6ca� tc the Person CouMy Health O��ent ibc a a�e aval�lon toc ths on-sibe sawaqa dbPo�i sy�ie-m
th� sbare�desaibed propecty. l agt+ee that the casrtenb of this applk�on �s tt� and ro�eni the moodRunn faaBltsa bo
ptscsd on the propecty. 1 w�tand if tha si6e b altared a the ��bended us� c�tau�pes. the pe�rn� sha+i beccros imra�d. l underst�
tl�at as apQBr.a�rt� I am �espon�bie fa idec�iiying and rtmrlcin9 P��► ii�a. canecs ard awldng tl�e ai6e a�e ibr
pecsonnd af tt�e Pessot� Cainty Hes�h Dapartment io condud their avalt�tians. I�nd ihat 1 am teapo�e �' �Yu►9
Hesah De�ttrnent if my properiy ca�afr�s any watlanda aa desi�na�ed bY ��mll C� ��-
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PEi�SON COUNTY EiVVIRONMEiVTAL t�EALTH �
°- PLEASE SE� ATTAC�iEi3 PLAN FOR SOIL AREA AND S'YSTE3V1 LAYOUT
, -' Tax 1VIap #: � `Z � Puaal f ��'J .
Zoning Townahip r � vP� ~ ,
, AQpI(pnt 5aw� nw �t,W k( v� S ..
��: l�'� s � �lu,� P�l � � ,Ll�i-h�l�w �%n
Subdivbion:
� " ��s.cbon: taC �
Improveme�t Permit � .
� A huildinct aermit cannot be issued with oniv an imarovement Permit
New '� Repair Addrtion Type of Strudure � Water Supply �" e�� .
# of Oxupar�ts #•of Bedrooms � Other
Basemecrt? LI/Q_ Basemerrt Foduces?�.�
Projeded Da�y Flow: �� g.p.d. Pertnit VaUd For: �e Yeats 0 No Expiraticn
Proposed Wastewater System Type: (',oti v�vjf�� D hal
Pump Required?' Yes %C . No
Proposed Repair :�o�t, ve.,�l-, o r� a � n .. .� �,_
Permit
.St�i y .�51
Owner or Legal Represe�ati�re
Authorfzed State Agerrt:
�i
Date: � � `�D `'
Date: a- � D (i
The issuance of this permit by the Heatttt Oepartmeniin no way guarantees the issuance of other permits. The permit
holder is responsible for cfiedting with appropriate goveming bodies in meeting their requirements. This site ts
subject to revocation if the slfie plan, plat, or the trrteaded use changes. The Improvement Permit shal) not be
afiected by a change in ownership of the sits. This pertnit Is subject to compliance witfi the pmvisfo� of the
Laws and Rules for Sewage 7reatrne�t and Disposal Systems af the North Caroitna Administrative Code.
Authorization To Construct Wastewater Svstem (Required for Building Pertnitl
Type of Wastewater S �
ystem _��k.v�vho,,� Wastewater Flow: 36D a.p.d.
Fac�it}I Type: � 1�r> � ����"�ou� New f� Repair DExpansior� 0
Basement? 0 Yes No Basement Fnchues? 0 Yes j�No
C�oh'�r.
Wastewater Svstem ReauirsmenLs ' - � '
Septia Ta�dc Size• L�a U gapons Pump Tank Size: �- gatlans
Total Trencf� Length: � f�ee! Maximum Trench Deptf� %� incfies Aggregabe Oepth:� in.
{�<<tlhtWq '
-�rSoii Cover. � inches Tr+enct� Separation: � Feet on Center
Other.�' lDu A�cir'��on�,' Sfl►�� CoVPfi pVP.f' P.t�li� S�P'�Z -�,�e� 1'c�u�►"�'r�►.�'
Permii Expiration Qate: — ? — � l�
Authorized State Agen� �Jaffi• � P�- �7 D 6 .
The type of system permitted ❑ does 0 do ot. diifer from the type specified on the appiication. 1 acr,8pt
the specificatlons of this permit
OwnedLegal Rept�esentative Stgnature: Date: lf� 7" �'`� .
PCHD, rev.11/18199
• . i .,
. • � � Applicatlan #: � ' .
. . . . Tax M�p 1�: � � a •
� Parael #: � 3� 3 .
� Porson County Health Dopartrnerlt . � . . ,
Envirenmental Health 8ectlon
� � 81TE SKEiCH .. • � �
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, pp Ic t's Na e • 8ub Ivlelon
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Authotlzed 8tat ent Date . � � � . ,
Syilem con�pontnls r�prea�f apProalmale conlours on�►. The contraclar mustJlag the ayafsm
. prlor M be�tlnr�hu� �Ji►a /nnallMlon to lnauro tha� proper Rrode it malntalnsd. , .
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6oale: � �
.•n��rr ...,.. �nM9/Ap'.
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�, .. � � ` � Person Counfiy Heaith Department
,, - Environmental Health Section . �
, ..Tax Map �: l�" �0 Parcei #: 3 Z 3
Zoning: Tovmship: ��a� 'ver
Subdiviston: � 0.�-� �P 'f�' S Section: _ Lo� �h
Applicari� � m �w"�
Location• / � � S �k.hvw �dY�
Operation Permit
System Type (In Accordance With Tabie Va): �-- Co-T �r-
THIS SYSTEM HAS BEEN INSTALLED IN COMPUANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
- ONSTRUCTION
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PCHD, rev. 10l12/99
Person County Health Department
Environmental Health Section ( 1 ,
Zonin • Townshlp: �1a 1 �( Je �"
9•
Subdivision: ��� Q v�v�eS_ Section: Lot: �_
Applfcant• ���''ty tt�`<►%`�.s
Location•
t�� s � i-(� ►�' ��m � f�-
Operation Perrnit
1. LOCATION AND SEPARATION DISTANCES
A) System meets .1950 setback requirements �e�
B) Distance from system to any wells --
C) Distance from septic tank to foundation f� �
D) Distance from system to property lines �b' v� � n�"" u�
2. SEPTIC TANK
A) �sually inspect the e�erior wails and top of the tank �S
B) Visually inspect the interior walis, baffle, tee, filter, riser, ids, air vent,
bottom, and water tight outlet ��S "�-
C) Date of tank manufacture lo - l 8- o O .
D) Tank seriai number ST8 ��f Z
E) Liquid capacity of tank � (,o � v gallons �
3. SUPPLY L1NE TO TI�ENC�HES
A) Grade �P,ed ►'Aw� r� (1/8 inch per foot minim ) PU�
B) Material supply line is constructed 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) tp the trenches %V �
D) Is the device on a level foundation l�'�
E) Does the device. perform according to its design s ecifications �
� Record the inlet and outiet elevations /V' �
5. NITRIFICATION FIELD �
A) Trench depth �T inches
B) Trench width �<- inches �
, C) Distance between trenches � ��
D) Number of trenches 3 i
E) Length(s) of trenches / a5- I'�� I o 7 �D 7'��^�
F) Aggregate depth «s �
G) Aggregate mate�ial and size ���
H) Record septic tank out�et elevatian 3- �FR
I) Trench grade � dve�ud c�S (< 1/4° per 10')
J) Step downs
a. Minimum of 2' of undisturbed earth � es
b. Proper rise over step down �
c. Solid pipe used � es
d. Elevations of step downs�ccl�u (Record elevations and show on as built)
See "as built" plan on attached sheei.
PCHD, rev. 1Q/12/99
PERSON COUNTY ,ENVIRONMENTAL HEALT}-1YOUT
• PLEASE SEE ATTACHED PLAN FOR WELL SITE �LA
Tax WP �:
�-�o �� 3�3
Zoaiog
Tnwnahip ��� / c �
�/'1��i?G% �/ �'� ,LJ S
�u� —
Loeatlon: 1 S^�
�-. t Y� � �',, �i" ��
��t� � gadioo; �-0'�--.1=
Sub�vislorc •
TvUe of Water SupplY:
Rectuicements: .
Weil Permit
��
� Individual Communii�l . Public
Site Approved by.� �-� I• 2 s� �
Grouting Approved by � S_ ( ��-S'nl
Well Log /�S I- 2s • o t
Weil Tag � � � �
Air Vent � �
Hose Bib �
Concrete Slab �"-
Well Driller: %7� r ��� .
Weil Approved ey: � - /
�
Date: �
**See �Attached Site Sketch**
Wells must be 10 feet from property lines. I ►
Weils must be �feet from septic systems. � 8� �'�'''�' �"�v`"
Welis must be at least 25 feet from any building foundation.
Other conditions:
�
PCHD, rev. 11/Z9/99
w . '. PERSON COUNTY ENVIRONMENTAL HEALTH
, � : .
WELL LOG
. � Date: 23 0 ' -
- Owner. (�C� M �i�l�y-- � SR# ' � .
Location/Directions: � �
Subdivision Name: C� ��1r1-P�1s�- C��S Lot # '-
Drilling Contractor: � � ��
WELL CONSTRUCTTON
Distance from Nearest Property Line 1 v Distance from Source of
Pollution ( G �
Total.Dep.th: IZd Ft. Yield: 1`� GPM Static Water Level a.� Ft.
Water Bearing Zones: Depth �`t F[. cps � F� 1g . F� Ft.
Casing: Depth: From 6 to�Z Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel
If Steel, does owner approve: Y�s No
Weight: Thickness:� '� Height� Atiove 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 / Coricrete
Annular. Space Width � Inches ,
Water in Armular Space: Yes No
_ .. Me.thod: Pumped � - Pressure � Poured � � - � � � -
Depth: Fr�m O to �, O F�
Materials Used: No. Bags Portland Cement Weight of .1 ba�_lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes � No � � �
� 4 x 4 slab Yes i No
DRILLING LOG �
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C�`viJTY HEALTH DEPARTMENT.
l2 _.. ----
gnature of Con�ractor Datc