A40 327�licatlon Date� � � �� � �
_ ,,ount Paid: � � '� � �
-- �i t #• .� i., ���'
Tax Maa #: �'��.
, parcei #: � .,�..�1
Perso� Coutnv Heaith Departmetrt
Environmernal Heaith Sactlon
. apQuca�ow FaR s�nc�s .
r'
�
IF THE 1NFORMATtON IN THE APPUCATION FOR�AN IMPROVEiYIENT PERMIT 1S FALSiFiE�. CHANGE�, OR THE SiTE IS
ALTERED. THEN'TFiE 1MPROVEiNENT PERMR AND AUTHOR1ZATfON TO CaNSTRUCT SHALL BECOME IM/AUD.
� rmit requssted by: (ownerlage�tfpcospealive oame�: ��
� Home Phone: • Ad s: - � ' • �t � � �
Bt�siness P � p'=� =�' L,"'� fl'� �,�.
' " .c�"�w.� r�� �� � C�l /' � � -9-�' �,� � /,.
2) Name and addcess cun�e�t
. �, ;u f ° �" .�-°
� j� �.� � N�
.�� .
3j Praperly Deseriptfon: Lat stzx
Di�dions to the property (Irtd�
4) ptoQoaad U�e and Struct�tre
a? PfoPosed 1� 6�n9 Q
� To� �1.�L1C+`v t`' j"
s� >4►1.� � � nl�9gb�s).
� r•� )
°'�' ''�'G TG�1.? ` . S'`K'h� ���
�
�tl"�P�
Deacriptton: answer eact� af the foUowing qu�:
b) Sticfc Bwlt Q Moduiar Q S'ingie Wide Q Double Wide �
� Number oi 8edrooms: ,,,,� � Number of �ts or peopie Co 6e sesve� �
e) Haseme� Yes O. No �li yes. # of basement tbdurex _
f� Garbage Oisposat Yes Q No •
g) Oimensicns oi Proposed Strudcue: Wtdth: � Dept� f�(Z
� Wa�er SuPPht '�Ipa: Privata 0(new �Cac e�dstln9 �. PtibRc 4�Y 4.�9 ��
Are any wells on adjoinin9 ProPer� Yes Q No � lf yes, lacatioo
�lease Indicate De3i`ad System iype: (sysb�na can be n�ioed In or+der of your poefere�csl
�ecrticnal Modifted Canvetffionai _ Altematiw Innovativa
Other (s�Cilyj:
-% � CLEARLY STAKE ALL CORNERS AND UNES OF THE PROPERTY.
- STAKE THE CORNEitS OF ALL PROPOSED STRUCTURES.
" Pt�ASE ATfACtI SURVEY PLAT OR SRE PLAN TO TH13 APPUCATtON
1 hereby rtiake app&:attort ta the Pe�san Cou�y Health Deparhne�t toc a s�e evaW� for tt� on-aite �wage d�al sYst�n fa
the abovadescxtbed ptoQerty. l agrea that the r.o�tents of this a�pHc�fioc� ace true and tepresent the ma�dmum fa�tes tc be
piaced on the propecty, t undeistard � the s�e is aitered a� the intended use ct�artgea. the penn& shaU become inva�d- � un��anc
that as aP4�cant. 1 am �spansbie, tor ide�ying and maridn9 P�Y �. �s and mak&►g the s�e a�a foc thi
personnet of the Person Caurrty HeaHh Oepacbment to canduct theic eyaluatlons. l unde�and 1lmt t am tBspons�ble tor no%[ying ttu
He�a�h Departrneat i� my p�perty centatns a�ry wetlands as desic�ed bY the Arm�l Cacps of �eets-
�C Q -� �-��.
Owner or tegai R . Oate
�licatio�a Date• 'Q � �0 � �
Amount Paid• _
Receiat #: � t , � �i �
��
�
�zs oa
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� �
Person Ccuntv Health Department
Environmental Health Sectlon
Tax Map #: ��'�
-.
Parcel #• � �
. APPUCATION FOR SERVICES .
�F THE INFORMATION IN 7HE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSiFlE�. CiiANGEO.OR THE SiTE IS
ALTERED. 'THEN'THE IMPROVEM_ ENT PERMR ANO AUTHORIZATTON TO CONSTRUCT SHALL BECOME INVALID.
�ermit requested by: (Owne�iageaUprospective ovme�: ��
� Home Phone: � Ad ' C� � � �
Business P - --- .c�'�w� r� �� � P,� q� h ��`/ �('� � �1 �P j
2) Name and address o cucreat c r. f�-�-1 ____ � � U-�-
N p
. � � a� � c1�
1,, °�� �� N-
3) Propecly Description: Lat size: � Towr�.shtp:l��� ��`
Diredions to the property (Indudu�gp� d names and n�j1��r�vc}; I� 7 S '-%U ��
Q n � � 8 M, � fi 1U� ( h, ) ; SF1 n� � r1 f�
4) Proposed llse and Structure Descripttan: answer each ofthe foilowing ques�ons: `�
a} Proposed � E�dstlng Q
b) S�cic Bu�t 0, Modutac �. Single Wide �. Dcuble Wtde t
c) Number of Bedroams: ,� � Number of occupaMs or people to be secved: �
e) Basemen� Yes Q No �.If yes. � of basement fudures:
� fl Garbage Disposal: Yes �, No ■
9) Dimensions of ProQosed Structure: Width: ��- , Depth: �,
� Water Supply Type: Private q(naw �oc exlsting �, Pubtic Q Community �. Sp�ing 0�
Are au�y welts on adjoining propert�/? Yes � No � If yes, loca�on
�lease lndicate Desired System Type: (systema can be ranked In orde� of your p�eference)
Conve�tionai Mcdifled Conventional _ Altama�ive Innowative
Other (specifyj:
CLEARLY STAKE ALL CORNER3 AND UNES OF THE PROPERTY.
STAKE THE CORNERS OF ALI. PROPOSED STRUCTURES.
PLEASE ATTACH SURVEI( PLA►T OR SRE PIAN TO THIS APPI.iCA'CION
I hereby make application to the Person Ccunty Heaith Department for a site evaluation for the on-stte sewage disposal system foc
the above-descnbed property. ! agrea that the cflntents of this app�ca�on are true and represent the maximum faa'Gttes to 6e
placed on the propecty. 1 understand if the site is alteced or the intended use ct�anges� the pe�mit sfiall become invaqd. l understand
that as app�carrt, i am responsble for identi�ifying and ma�idng propeciy lines� comers and mald�g the site aaess�bte foc the
personnei of the Person CouMy Heatth Oepa�tme� to condud thdr evaluations. I understand that l am responsble for not�fying the
Health Department if my property cor�tains atry wetlands as destgnaie� by the Army Corps of Engineers.
�n Q `) �-�v.
Owner or Legal Represe . Oate
� ..
PE�SON COUNTY EiVVIRONMENTAL MEALTH �
PLEASE SE� ATT�4CHED PLAN FOR SOIL AREA AND Si(STEiVI LAYOUT
r� �P �: � �4- �0 P�� � 3 Z-
ZoNng Township � � . ,
T . . /f . i ..
APPiiea
LocaUa
Su6dirisiom .�----- Saetlon- '� Lot �-�
improvement Permit .
A huildinq Qermit cannot be issued with oniv an Imarovemerrt Pertnit
New � Repair Add'iU'on Type of Strudure �i��er Supply f�'v'c��-z G,�'E'l`
# of Oax� ants #•of Bedrooms `''' Other ---,
Basement? 1����Basement Fbc�ures�J
Projeded Daily Flow: - �� g.p.d. Pe it Va d Far: t�F' e Years !0 No Exp�on �� �_
Proposed Wastewater SystemType: o � • he� w7"� o «f�a,�ys �y`..� �
Pump Required?� Yes a/No � \ /
Proposed Repair: T,�,� ,!c..� �' �o��,.�,�r�,.e_�y�rp� ���crL'/�c:�.,.�s `J
Pemut Conditions: � �� � ,
Owner or Legal RepreseMative Si"gnabure: � Date: % l`
AuthoRzed Staie Agerrt: � Date• �a —�%' �d
The issuance of this permit by the Heattl� Department in no way guarantees the 9ssuance of other permits. The permit
hotder is respansble for chedting with appropriate goveming bodies in meeting their requirements. This site is
subJect to revocation if the slte ptan, plat� or the irrtended use cfianges. The Improveme� Pemnit shait not be
affeoted by a change in ownership of the site. This pertnit is subject to campiiance with the p�ovisions of the
Laws and Rules for Sewage 7reatrnent and Disposal Systems of the North Caroiina Adminlstrative Code.
�-. � r
Type of Wastewater System � .� Wastewater Flow: 36� �.p.d
Fac�liiy Type: 3 °c�c�-�..e,.�. New O�Repair �Expansion 0
BasemeaC? 0 Yes o Hasemerrt Fixhues? 0 Yes C1tiQo
Wastewater Svstem Requirements
Sepdc Tank Size: d�� gaqons Pump Tank Size• � ganons
Totat Trend� Length: �v feet Maximum Trench Depth: L],,_ inches Aggregabe Depth:� in.
�h�P�oil Cover. ,�,_ inches Trench Separatton: � Feet on Center
Other. SP� S��e :5�.�� �
Permit Expiration Date• �-/ — DS
Authorized State Agent � �� � �%,? //�''�
The type of systsm permitted �oes 0 does not. differ from the type specified on the application. I accEpt
tl�e specifications of this permit
OwnerlLegal Representative Signahue:
Dabe: ����
PCHD, rev.11/18/99
. _ .----- ___ .. _._. __....__._______.._... _.._ _ _.
Person Counfiy Health. Department
Environmental Health 3ection
�Q/1.eS �C' �C�k �st...oh
Applicant's Name
' �, S.
Authorized State Agent
SITE Sl4ETCH
Tax Map #: /� � ��
Parcel #: � � 3 7
SubdivisloNSectiaNLot#
��-/ / ��
Date
System compone�s represent appraur3mate coretours only. The cuntractor must flag the system
prior to beginntng the installation to i�rsure that proper �rade is maintained
v �� �
�. �(� `'��-� �5��'/"CDvers�.��� ,
Y-'eP i /'�� �.e c� (/`eY6%'�-�i�.�"
S �� s-���a�
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2. -�4 s7�rz �j',� 4, �- ar.P�s a/'�2 T��� R�l"
4�c,�'o•� s,�� ,
0
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Scal@: p= � �
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/�ecPSs.�S�l�z�
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/ �On �s.�pi".S' �a^ /
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. _ __ ___ .�._ _ . .. __ _. _._......_ _.._ _--- - . _ . _. _.. .
Person County Health. Departrnent
' � Environmental Health Section T�c Map �: �.� 9
Parcel #: �� .
SITE S14ETCH � _ ..
�a/�.es �'c�k nti.�., _ . ,
Applicant's Name Subdivision/Secfion/Lot#
' ��-/ / -t�-e7
� s,
. Authorized State Agent Date � �
Syste�t compone� represent appraxinrate cnntnurs only. The contractor must Jlag ihe system
prior to begin� the installation to Insure that proper grade is nraintained
V �� �
/, �(o `'�� �5��'��ve,- s��� .
�'e ��/'.�� .�� d V`e�' '�
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.{re �. � .
2. � s�.. ��.� ,;- a.��� a��e 7`���Q9�
��t.�'on Sr"i�
� 2og'
15��
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Scaie: �= D' �
e
�c�SS A''cS2J2�z�
30��
�.�s-
'� �'t'.'r /�i'ecL
3�' �/�.�� ��� � �� s{y �e�. •
/� /'� �7`� or��r��
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q °�� ��e�-.� ia� ,i�
Gl'��i
r
�� Person County Heaith Departrnent
Environmental Heaith Section � 3 � �
Tax Map #: ,� Parcel #:
Zoning: Township: r� � t)�P�
Subdivision: Section: Lot:
Appiicant• �G'Vi'�-� � i GI��Q� �
L� � 1 ` '
Location•. � �7 � � � o/�!� � T�(P_ l � "�7 a ' r` `�� ��'
�
�peration Permit �zZ�
. �
� System Type (In Accordance With Table Va): �—
THiS SYSTEM HAS BEEN INSTALLED IN COMPUANCE WITH APPLICABLE NORTH
CAROLlNA GENERAL STATUTES, RULES FaR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF TH� IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZATION. ��fd� �
__ __-- � - �� f
� . I� ��- �
� Au rized State Agent �, ��� ' � Date
Tax Map #: Parcel #:
PCHD, rev. 10/12/99
Person County Health Departrnent -
Environmental Health Secfion � �,
Zoning: Township: �� � t��l�.
Subdivision: Section•
Appiicant: � �-d l.�r� /11�f /�
Location•
�-p �`-c/� . .
Operation Permit
1. LOCATION AND SEPARATiON DISTANCES
A) 8ystem meets .1950 setbacic r+equirements _ I��,..'��
B) Distance from system to any wells ��� ���
C) Distance from septic tank to ioundation s=,�wD
D) Distance from system to property lines �r � /- n
lot
2. SEPTiC TANK ,�
A) Vsually inspect the exterior walls and top of the tank
B) Visually inspect the interior walls, baffl�, tee, filter, riser, lids, air veni,
bottom, and water tight outlet `� �
C) Date of fiank manufacture a-aa-0 �.
D) Tank seriai number
E} Liquid capacity of tank rc��— 9alions
3. SUPPLY LiNE TO TRENCHES
A) Grade (118 incfi per foot minimum)
B) Materiai supply line is constructed from
C) Diameter
D) Length
E) Distance from tank to drair�field/distribution device _____._
4. DISTRIBUTION DEVICE(S)
. A) Type -
�B) ls Device water tight
C) Distance from the distribution device(s) to the trenches
D) is the device on a levet foundafion _
E) Does the device pertorm according to its design specifications
� Record the iniet and outlet elevations
5.
NITRIFICATlON FIE1.D
A) Trench depth ja' inches (
B) Trench width �inches � Q� C�
C) Distance between trenches
D) Number of trenches � � � ��a r '?� � a �
E� Length(s) of trenche� �
'� Aggregate depth �� inches
G) Aggnegate materiai and size
H) Recorc! septic tank outlet elevation ��%�
i) Trertch grade � �- (<_ 1/4' per 10')
. J) Step dovms � ,�
a. Minimum of 2' of undistu� earth �_,
b. Proper rise over step dovim � .
c. Sofid pipe used � o�(a�;�
d. Elevaticns of step owns S�'(Record eledrations and show on as buiit)
See "as built" plan on attached shee#.
PCHD, rev. 10/12199
Ta�c MaP #:
pERS�N C�U{�TY EiVViRONMENTAL HE.�LTH
-- -- - -- ....... .,.r-. � ��r� � w�
l.� _ Pa�el a
t
Zo�ing T��I
�Pu�
�casaon:
��....:_��r. l�` � ��
♦� �, �, 4
, / �
Sealon: �
Subdhrisioe. .
Well Permit
yae of Water Suaalv: Individual Community Public
Reauirements•
Site ApProved by �
Grouting Appr� bY
Well Log
Well Tag /
Air. Vent
Hose�Bib �
Concrete Slab /
Well Dritler:
Well Approved By: � •
(..� r r c%Q fit%
�
Date: � �
**See Attached Site Sketch**
Weils must be 10. feet from property lines.
Wells must be 100 feet from septic systems.
Weils must be �at least 25 feei from any building foundation.
Other conditions: �
PCHD, rev. 11/29/99
. �.�..._ _ :,
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date: ' za o1 '
Owner: �`
Location/Directions:
Subdivision Name: __
Drilling Contractor: Z� �
SR#
Lot #
WELL CONSTRUCTION �
Distance from Nearest Property Line I v Distance from Source of
(� ��
i `-' �
Pollution ( G a
Total.Dep.th: 17o Ft. Yield: l� GPM Static Water Level Q2S" Ft.
Water Bearing Zones: Depth �_Ft. � F� F� �t.
Casing: Depth: From 6 to U Z 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 Froblems Encountered in Setting the Casing? Yes No �
Ir "yes" give r�ason;
Grout: Type: Neat Sand/Cement / Coricrece
Annular� Space Width - Inches � .
Water in Armular Space: Yes No
_ .. Method: Pumped � - Pressure � � Poured � � - � � � -
Depth: From O to � � 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 � No
I HEREBY CERTIFY THAT THE ABOVE INFORMr1TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C�ui1TY HEALTH DEPARTMENT.
c .
naturc of Contractor Da«
►