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��opcatlo�a oai.• � o-��� a
Ant�ount�Pai=d �— a��'
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Perso� Cou�v Health Oeoartrnu�t
Environmenta! Heaitl� 3ectlon
�- � . �. - - �:�� ��
T��o� �-�°
F+ar+esl �i: .�� �f
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1F THE INFORNIATION IN THE APPUCA710N FOR �AN IMPROVEiV�ENT PERMIT IS FALSiR�. CtiANGED. OR THE SiTE IS
�TERED. THEN'THE IMPRONEiIAENT PERMIT AND AUTHOR1ZATfON Ta CONSTRUCT StiALL BECOME INVALID.
1) P.nnit r�sq„eaied hy: (owt,ertagentlprosp�ttv. owne�: s A'�h M X A w ,ys �
HOrt1s PhOpn{�, � �� � S�` Y � Ad� �'F �" .1f � �P p /�- � , cG � 'P�
8� [-I IY170• ��0 ..�'P �i r% R��1 I�� s.�.. �. � � �
��iaR10 dfld iddl0�: Of CWl�1t OMRtdf: • S A^' �
3) Proputy �.s«tpSoc� t.oes� !, 99 T� �; ��
Diredto�s to !he Pr'operty (f�9 toad �acttas and nurnbeisx �° P F �t IJ.
4) Ptopoa�d Ua� and Struet�tce Descriptlam anawa esdt af the fo0c�w�q qceeatlona:
a� Proi�osed Q� �ds�q 0
b) Stidc Bu� Q Moduiar L'� Sinple W(de Q Dout�le Wide�
c) Numbet at Bedtoom� � � Nuttiber of occ�anis� ac peapla to be senre� �
e) Baaem�nt Yes q No 8'� yea. � ot bassrt�ant fixiucex
�� Gacbaqe Dis�Osak Yes q No 0'
�i Qin�sbns�vf ProQosed Strtr�tu+a: V1Adtt�: �� DaR�lt� �O
��r �+PPhI �'YP� P�ivata �new a ar eodatln9 �1. Pubwc 4 Comixa�tY [1. Spdn� 0
Aro arty wepa on a�oining pc+operty/? Yes 0 No �tfyes, lo�tton
6� PIas.Indicat. c.eii.a Syst�m'TYpe; (aystoma can bs rrala.a 1n c� a your p�)
'�Convecttlo�sal Yoc�fted Corn�ntional _ Idb�atlw ..,�nnovaflva
0!!wr (sQ�3[y�:
CLEARLY. STAKE ALL COEt�IERS A� L1NE3 OF THE PROPER'tY.
STAKE THE CORNERS OF ALL AROPGSED STRUCTURES.
PL�113E ATTACti SURVEY PUIT OR SRE PUW TO THl3 APPt1CATiON
I hereby niekn app6catlon to tha Pe�on Camty Health 0� ibr a s�e avak�atlon for tt�s on-siie sdwapa dtsposal sysiem
ths abane�descxibed propeciy. t aptee tl�at the cont,en�t af thia applicatlon a�e tr� and cepcesent the maodnuun f�ties bo
ptacad on the pnoQe�ty. 1 unde�and if ths s�a is altec+ed a ths inmrded uss d�anqes. the pem� sha�Y becane inwii�d. i ws�etst�
1lt�t as ap�rtt, 1 am respor�e fa ida�tiying and rt�a�lCin9 P�P�Y �, canera and taaking tha ai6e ac�aaibie iar
pecsonnal of the Persa� CauYiy Hesdh DeQartimart to condud tt�ir evaksaUcru. I�atand lhat 1 am t� ��9
liealth D art !f my �s any wetlanda as dai�m0ed bY ��Y � a�
w ��
-� o _(t_oa
o� L�1 Re�a�t�ve . Oa�e
If�ir7
J'�
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� ' � P�E�St�N CL3UNTY E�iV1RONME�ITAL MEAL-TN
� '- Pl.�.ASE �E� A�d'�CHEi� P1�N F�R S�tL AREA AND Si(STEM L
' r� �+ � � �0 �,r 3�� .
_ ���
pppila
Locatla
Tewruhie f' llJLl I 11 �/l� %. _
Su6dwlslon: ���``^ t�f�� S�dlaa: LoC�
� Improvement Permit � .
A huildin4 �ermit cannot be issued with only an Imarovemer�t Permit
New / Repaic Addition Type of Strudure� Water Supply �2 , .
# of OccupaMs #•of Bedrooms � Other
BasemeM? �/�-8asem�t Fodtues? „��
Projeded Daiiy Flow:��0
Propa� w�stewater s,rst�
Pump Required?' Yes
Propased Repair • �
Pem►it Cond'itions: W _Pn
Owner or Legal Rept�eseMative
Authom.ed State Ager�
Permit Valtd Fa:�FHa Yeats
i� �UO�,�(ol��
lo
��`� � � -�� ��,/� ;
�s�.,A,u ��.� „/,
0 No Expiratlon
��
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ot /'/a/ov
The issuance of this perrnit the Healti� Departme�rt In no way guarantess the issuance of other p�rmits. The perm�
holder is respansibie for ec�ing with appropriate gweming bodies in meeting their requiremeMs. This siie is
subject to revocatlon ii th site pla�, plat, or the iRteaded use cl�anges. The improvement Permit shalt not be
affected by a change in ownersfiip of the site. This pertnit ia subject to campliance with the provisions of the
Laws and Rules for Sewage Treatrneat and Disp�al Systems of the No�th Carolina Administ�ative Code.
Authorization To Construct Wastewater Svstem (ReQuired for Building Permitl
Type of Wastewater System �n ��n /lOh � VUastewater Flcw: � 6 o a.p.d.
Fac�7ity Type: 3 r�'". s- � p• � NeW�I Repai' �Expansion 0
8asement? 0 Yes � No Basement Fotturea? 0 Yes�d iVo
Wastewater Svatem Reauirements
Septic Tantc Size• �� C� gai(ons
Pump Tank Size: '—'' galtons
Totai Trentch Length: � feet Ma�dmum Trend� DeptK � indtes A99�9� 0�:� m-
/�3�is�im+[n� .
�wm Sai Caver. � inct�es Treruh Separatian: � Feet on Center
� Other. Gr � �
CrDr��OGu^.
Pemut Expiratton Date: , � 01 ✓ 6 ✓
Autharized State Age� ��; �• �"' � � .
The type af system pertnitted 0 does Q do not. difter from ttte type specifled on the appiication. I acr,apt
the specificatians of this permit
Ownerltegal Re{�reserrtattve Sign p�;/ /f i •
_ • PCND, re+r.11/18199
. -� ,
, ., , . .
' � . • ' � PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN F�R WELL SITE �LAYOUT
. �4-� �� 3 � n
Tax wP �: ,�
Zoning Tawnshlp / �L %
.
s�m��: � 4� �t-' s°w°�: . � �--
Weli Permit � �
Tvae of Water Suaalv: ✓ tndividual Communiiy . Public
Rectuirements•
Site Approved by ��S I� a�• o�
Grouting Approved by �� �S • 2S- o j
Weil Log � 2S •a � • �
Weil Ta S • 25 o t
Air Vent � � 61
Hose Bibi
Concrete Slab / �
Well Driller: '� ' Y �
Well Approved By: '
�
Date: 2 � � �
**See �Attached Site Sketch*'"'
Welis must be 10 feet from praperty lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
�
;�
,;
�
� PCHD, rev. 11/29/99
w .
. _ _---`.. _ . .. ..._... _...._._...__.._. .... . . _._ .
- • � �P�rson C�unty Health. Departrnent
' � ` ' � E�vironmeniai Hesith 3ection �0�
- � Tax Map �•
. . .
` _ Parcel #: a�
0
�.
Sii'E S14ETCH _ . .
- -��GtIyJrYi ��v�c�hS � lV��cr � �S La �. �C
il s Na e Sub i�ision/Sedion/Lot�
i �— I 2-- �c�
. Authorized S Ager�t Date � �
,System co�ponert�.� repr.esent appm�xima[e cmetvros only. The co�or mustJiag the sys7ene
prior to begi�[n� tlie installatioR to i�sta�e thaZ P�Pu' R�'ade is nrafittained �
� / .
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1 � ��,�` a �a-- �a .
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-r ple VJ'� �•Ef •
3 �p e�:'re r "` �
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• .y _ �,,,��...,,..-- _ — !d` F�/��
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'�' � ��� ��ce b! O � O
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�d'x 3 � �%� �e;�`7o�1
�;i,a i S� f�1� s�s�n.
� � .,,�; a�e �1
jg� m�,x���m -� (�
R�_ _ -�� N ov ��-�v� __� -
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sca�e:
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. � . � � Person County Health Departrnent
r �� ' /� Environmental Health Section , � �� /
Tax Map #:
l� � D Parcel #: `t
Zoning: Tovmahip: T'•l a, � j�r �/� f _
Subdivision: G� �'v�� • A� �°S section: _ Lot `r �
Appilcariti Sa�, `K y-�� c✓� i� S
�
Locatlon• Fl���,h Q✓� ��� i��� �•
Operation P�ermit
System Type (in Accordance With Table Va): �� � h �-
THIS SYSTEM HAS HEEN INSTALLED IN COMPUANCE WITH APPLICABLE NORTH
CAROLlNA GENEiZAL STATUTES, RULES FOR SEINAGE TREATMENT AND DISPOSAL,
AND ALL CONDITiONS OF THE 1MPROVE�AENT PERMTT � AND CONSTRUCTION
AUTHO ON � �
, �,� I - S-D I
Person County Heafth Department
Environmentai Health Section �� �2 �� e✓
Zoning: Township: F
Subdivision• �^-������ �G�� S Sectlon: Lot: � �
Applicant: ��^�� rTc.w��ws
Locatl"on• � � � �� I��-i'� ��
Operation Permit
1. LOCATION AND SEPARATION DISTANCES e S
A} System meets .1950 setback requirements
B) Distance from system to any wells W�« n1
C) Distance from septic tank to foundation �S'
D) Distance from system to property lines /D ��„-
2. SEPTIC TANK
A) �sually inspect the exterior walls and top of the tank y e s
B) Visualiy inspect the interior walls, baffle, tee, fiiter, riser, tids, air vent,
bottom, and water tight outlet yes �~
C) Date of tank manufacture `�- s-oo ,
D) Tank seria! number STR I�{ 2.
E) Liquid capacity of tank � � o 0o gallons �
3. SUPPLY LINE TO T�ENCHES
A) Grade �e drawi►�q (1/8 inch per foot minimum)
B) Material supply line is constructed from sc,l� 4o PV c�
C) Diameter 3 �'
D) Length � 6
E) Distance from tank to drainfieidldistribution device ��
4. DISTRIBUTION DEVICE(S)
A) Type N � �
B) Is Device water tight N�
C) Distance from the distribution device(s) to the trenches /� �
D) is the device on a level foundation ?� �
E) �oes the device. perforrn according to its design specifications N A
F� Record the iniet and outlet elevations NAc
5. NITRIFICATION FIELD
A) Trench depth /� inches
B) Trench width 3� inches � _.,L
, C) Distance between trenches �i o h C2�,Pr�
D) Number of trenches l
E) Length(s) of trenches �fo, l n S� 8�1', ga � Sq, So ��f35� lv �J
F) Aggregate depth � inches
G) Aggregate material and size #��
H) Record septic tank out�et elevatian `f • I'
I) Trench grade �'te d r�u'„'� (<_ 1/4° per 10')
J) Step downs
a. Minimum of 2' of undisturbed earth Q s
b. Proper rise over step down e s
c. Solid pipe used Ps ,
d. Elevations of step downs 5°.���w (Record elevations and show on as built)
See "as built" plan on attached sheet.
PCHD, rev. 90/12/99
PERSON COUNTY ENVIRONMEftTAL HEALTH
WELL LOG
Date: �� o � �
Owner. O �
Location/Directions:
SR# ' � � �
Subdivision Name: __ �(�r(r1�'1��� 5 Lot #� y-� —
Drilling Contractor: � � ►��
WELL CONSTRUCTTON
Distance from Nearest Properry Line ! v Distance from Source of
Pollution ( G a
Total.Dep.th: llnb Ft. Yield: 30 GPM Static Water Level a.r Ft.
WaterBearingZones: Depth�_Ft.�3 F� L�s. Ft� Ft.
Casing: Depth: From 6 to�Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel
If Steel, does owner approve: Y�s No
Weigh� Thickness:� '� Height Above Ground: 1�/ 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 Aruiular Space: Yes � No .
.. Method: Pumped � - Pressure - Poured � � - � � - �
Depth: From O to �. � Ft.
Materials Used: No. Bags Portland Cement Weight of .1 ba�_lbs.
If mixtule (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes � No � � � �
� 4 x 4 slab Yes i No
I HERE'BY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON COi1i�ITY HEALTH DEPARTMENT.
nature of Contractor Da�c