A40 328� F�mo�nt paid ���' oO
Receipt 0 �
���`%JO
- . .� �� -
l �
1���
Improvements Permit.(EstablishedlRecocded L.ot)
Improvements Permit (Unrecorded Lot)
Improvements Permit (Mobilc Home Replace)
Improvements Permit (Addition)
� �� Q �
� ��-�J,36.
J
. .�>._: ..
�-`��
Date
;.� -: .
Reinspection of Existing Sys[em (Loan CIosing)
Repair/Replace existing Septic System
_ Pecmi[ for New Well
Replace Existing Well
�
�
�
w
U
�
a
,
�.
1. PerTnit requested by: .
owner/prospective owne:/agent:_
Address: � � � �
/� /'� Y �r�' O /��i _
ome Phone #: 'S 1 7 `�So
usiness Phone n: �v4a�.� �
Name and addLess �
7�.4�re�L� �'.�
7. Dimensions or Pr000sed Structure:
Width: � F�
Depth: 7 0
�-S - 8. What type (if any, additions, expansions, or
replacement is anticipated to the scructure or facilicy
—�--- that this se�vage disposaI system is intended to serve?
�� ���
�C°
nt owner: 9. Water suoply t}•pe:
�t�ula� privace�j . public ❑ community ❑ spring ❑
� �.5 Are any wells on adjoining property?Yes ❑ No (�
� � �%� If so, identify location:
. Property Description: L,ot size:
Tax Mapn:
Parceln: _
Townshio:
��
�
. Direccions to property: State Road n& Road
iames,�tc.
�b u� �. t9 /l� /.iA. /� �`f/'7'r��l� T.n �.4v.�/�o<f —
?' iOAss�r�.! 7l�.�'�o
Number of occuvancs or people to be served:
10. Type of structure/faciIi[y: Proposed: �Existing: Q
Type of dwellin;:
House: ❑ Mobile Home: (�Business: ❑
Type of business:
Number of Employees:
Number of bedrooms:
Garbaoe Disposal? Yes No�
Basement? Yes ❑ No l'� If so, ; of basement fixtures:
CLEARLY STAiLE ALL CORNERS OF THE PROPERTY AND THE CORI�IERS OF ALL
PROPOSED STRUCTURES.
I hereby make application to the Pet'SOA COUIIty �3ealth Department for a site evaluation for the on-sice
sewage disposal system for the above described property. I agree that tf�e contents of this application are true
and represent the maximum facilities to be placed on the property. I understand if the site is altered or the
intended use changes, the permit shall beeome invalid. I undecstand that before an Improvements Pecmit ean be
issued, I must present a sucvey plat of the propeRy to the Health Dept. I undecstand that in the event I have not
delivered a survey plac of the property to the Health Dept. within 60 DAYS aftec the date oE the evaluation of
the site by the Health Dept., this application shatt become void and all fees paid forfeited.
f
G v
S gnee� Owner or Auttiorized Agen�
. -:
�
�
V
�
a
B 2931
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map # A�� Parcel # �S �
Zoning Township �a� iuci
Owner/Contractor aN;e � ��e�Nwood _ Date
Location/Address i57S. /��. o� %�v.��.s To���•� R�
ia�! �c�� �ri ��v.� .
Subdivision N
I,,Ot#
SEWAGE SYSTEM SPECIFICATIONS
��
S.R.#
[�epair Lot Area a, a7 /�C. Size of Tank %UUU
SFD Mobile Home Size of Pump Tank
Business # of Bedrooms 3 Nitrification Line yQ� `X 3�
Max Depth Trenches �y ��
Permits may be voided if si�is
Well and Septic Layout by '
Comments: S�c L'o.� •' �'v.�
_. „ , � � >.
Date �_ / �- 0
ell Permit Paid
or intended use changed.
Installed by � � �2� Approved by
t��, 1-� -b i`�(-�� 2. Zl 8
W LL SYSTEM SPECIFICATIONS
[ndividual Semi-Public Required Slab
Public Replacement Air Vent
Site Approved �/ ZS� 2—� �o Required Well
Well Head Approved Gj �� D Well Tag <
Grouting Approved S -0 � `
Comments:
o r o��
Date 5 31 �n1
This report is based in part on information provided the h�meowner or his/her
representative in the application submitted for this permit. The environmental
health specialist is not responsible for false or misleading information
contai�ed in the application. The environmental health specialist is also not
responsible for concealed conditions on the property or for statements in this
report that may have resulted from false or misleading statements provided to
him in the application. Neither Person Cou�ty nor the environmental health
specialist warrants that the septic tank system will continue to function
satisfactorily in the future or that the water supply will remain potable.
c:\amipro\permit.sam O1/95 rev.l.l
0
�
�
.
QI� //
`` '
� .� ��0�� /
� �/ NF �
6� ' � �
-" 1v�'� � �
Y �/ ���5 '�/ ,� �.
1� �
� ' / ���,f / IF
.
Q •F. .
S�� '� �.�k� 5�` /� j� r►�
T�
� , i
.
/,. � 25e• - �,�� b��,. �o
t ` , , Ca
CONTROL � � �I��G ��`�G
CORI:ER �
/ ►� /� la� ►�e"'���` �;s�s.
, .
�' �o �' bG b''' �
�
�CRES
.. �. .:,.. ��-
,
°•z�<<?.
�
..-' FRANCES GAVIS
- I. 198, P.. 213
4.
. �
_,
IF ��`
,,
��
,
Si1SAh
B£YER'.
B�RLAN:
���,�„„�„�,,,,��
��.� ��ARO(/N�'
� •.
,��0�••' �Sjf �4
c =: ��6 R£p '�
� $E AL
: � _„� � _
,i�. u n•
''•,, ,yN •.......
����'''•���� � � �E
�
Person County Health Department
�Environmentai Heaith Section ��- /
Tax Ma� #: � Parcet #:
Zoning: Township: �
Subdivision: ection: Lot:
Applicant• o Q� r� (�, l-P�i� �44
�
Location• .�J —' � �2l�%L `"� �'?� �'_' � � � �%0/"�
�� r.
��.��
�peration Permit
cordance With Table Va : C�������
System Type (In Ac )
THIS SYSTEM HAS BEEN INSTALLED IN COMPLlANCE iMTH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZATION. _
� ,� �o
Auth zed State Agent Date
�
��
�
S,o
3'
�
Il-�6_�0 'o
P5 �� � ►�r
�n �
�
�
1 d Co�,�
z
Tax Map #: Parcel #:
L%� t 7 sY'
c..� a � aa �
�� ^�- ,3 -� �d ,
1.:�. y� ��i
L'�` '`-a �Ia� /
L; n.�. G 7 8 6
'(o� �ID ►
PCHD, rev. 10/12/99
Person County Heatth Departrnent �
Environmental Heaith Section �
Zoning: Township: ��� � f v�J�
Subdivision: Section• l.ot•
Appiicant: �� �6'-P.P� uloocX
Location: l5 7 S 7(�'2c��C.,t� %�v�-r .�o�.c�� oi1 /� ,lx��
O eration Permit ����-�-
1. LOCATION AND SEPARATION DISTANCES �
A) System meets .1950 setback requirements �_
B) Distance from system to any weAs
C) Distance from septic tank to foundation
D) Distance from system to property lines I��
2. SEPTIC TANK
A) Vsualiy inspect the exterior walis and top of the tank �
B) Visually inspect the interior walls, baffle, tee, filter, riser, lids, air vent,
bottom, and water tight outiet �-eD �
C} Date of tank manufacture !-aOO�
D) Tank seriai number 5 �9�_
E) Liquid capacity of tank ,� oor� gallons
3. SUPPLY UNE TO TRENCHES
A) Grade � (1/8 inch per foot minimum�
B) Material supply line is constructed from 5� yp �U�
C) Diameter 4 ��
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) to the trenches
1 D) Is the device on a leve( foundafion
E) Does the device pertorm according to its design specifications
� Record the iniet and outlet elevations
5.
NITRIFICATION FIELD �/
A} Trench depth a 7' inches
B) Trench width �(Q_ inches L^ --�
C) Distance between trenches �� � -e�^-•
D) Number of trenches , � � �_ �
� Length(s) of trenches .5N ' a a` 7e 86 9a 86 -- �� �
'F) Aggregate depth � inches � � �
G) Aggregate material and size
H) Record septic tank outlet levation .�' 6'�
I) Trench grade � �� (<_ 1/4' per 10')
. J) Step downs �
a. Minimum of 2' of undisturbed earth �
b. Proper rise over step dovim �
c. Sotid pipe used _ �-� (�� � �
� d. Elevations of ste downs s�" (Record ele� 6ons and show on as buiit)
See "as built" pian on attached sheet.
PCHD, rev. 90/12/99
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date: �1 �� '
Owner. �R�L«�1.. �-►�i�
Location/Directions: ��t ��1�.� `�
SR#
Subdivision �Name: Lot #
Drilling Contractor: � /( � /2'�-� � �c
WELL CONSTRUCTION
Distance from Nearest Properry Line ! v Distance from Source of
Pollution ( G a
Total.Dep.th: 9 �(C� Ft. Yield: ��0 GPM Static Water Level �2.5—' Ft.
Water Bearing Zones: Depth—tc� F[. c_F� 1�C� . F���, �t.
Casing: Depth: 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 / Coricrete
Annular Space Width � Inches
Water in Armular Space: Yes No
_ .. Method: Pumped � - Pr�ssure � � Poured � - - -
Depth: From O to � C� Ft.
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 � No
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�'vi1TY HEALTH DEPARTMENT.
S' nature of Contractor ate