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Enviro�meMal Healtt� 3ectlon
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IF THE INFORMATiON IN THE APPL1CATtON FOR�AN IMPROVENENT PERMIT IS FALSIAF�. CHANGED OR THE SiTE IS
ALTER�D IF_i�l'THE 1MPROVEiYIENT RERMIT AND AUTHORiZAT10N TO CONSTRUCT SHALL BECOME INVALID
�) Pesmit requestad by; jOwaech_genyprospacttvs a�wne�: Sfl-�h y h`A ki •Nnvs .
Hans Pt�o� 3`' �i .2 ,S� �- • Ad� ,� ss' �� a� e� ,�j �.. � s�F'�o_
Btbineas Phoae: ,� - � IP c.YD 6.P e � a�S� 3
Zj Name and addt+ess of cun�ertt awner. S'�-'�' �'
3) Pioparty DescriQtlo� Lo! stz� � Taw�hta '�- R
Oirec�ns t8 the P�P�Y R �,cj �am��i and �umbersx I�'i%� � q O sl �� A N,G
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•� ProQosed liss and Strueteu�e Descriptlam anawet oact� of the fo�owin9 qu�:
� ProPcsed� E�dat6�g 0
b) Stidc Buat q Moduiar L. Single Wlda 0. �ouble WWe�
� Numbac of Bedtoomx �� S-`i. -� r� Number of occupa�� or peopk to be secve� ��
e) Baaame�rt Yas q No �tf yes. # of baaema�t fi�ducax
• t� Garbage Oispoaa� Yes q No�
� DLnenaionsof Proposed Strtx�t�a: VVidth:z� Depttx �°
� Wabec 8uppty 7j�pa: t�ivate q(r�w � or e�ds�nq �� Puh9c 4 Cocmnu�Y 4 Sp�ing �.
Are any w�eqs on a�oining properiyt Yes 0 No�'(t yes, loc�ton
6j Pl�ass Indiab D�titid Sysoam 'Type: (syatama can bs rrNaad In � ot Y� P��
r�Convantlonal Yodiflad Canhatlonal "Aldmaflv� . �nnovathte
CLEARLY STAKE ALL CORNERS AN� UNES OF THE PROP�RTY.
STAKE THE CORNERS OF ALL I�OPOSED STRUC7UI�ES.
PL.EASE ATTACH SURVEY PU1T OR SRE P�AN TO THIS APPt1CAT10N
I herob�l mnke � bo the Pe� Co�u�ty Heatfh D� 1bt� a s�e avabtmfion tor 1t�e cn-aiEe� sawaqs disPosal syaiem
tha abo�e��ad property. 1 a8[ea tt�t the �t� of ttds apQYcafion are pus and � the ma�dmum � b�
placad on the �+oQe�iy. 1 iu�c�d �the s�e b altered a�ths inbended usa draaipes. the pe�mitst� bemme inwNd. l undasts
tt�t as a�ppHcartt� I am rospo��is for idartiiying and maridn9 P�Pertfi 1i�ea, canas and meldc�g the a�e a�e ficc
personnel at the Per�an Cauity Hea�t► Oepartrna�t to con�ct their evakmtloc�s. {�and tfiat 1 am t� ��8
Heaah D if mY AroPeriY anY waUanda as da�i�0ed bY tKe ArmY Co�ps of 6�s-
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T���: f��o P�� �--�- 33a _. = - _ ..
Zoning Torvn:hip �� � /�!/��P— ".
appueanC �Gi fn r►.L w Ci , ..
loeatlon: I'v i l� ' jc LG�� it�2 'o� fTNf f K61 •
suhdivbloa: �2�9Q �1�i - - — �dlo� �� 6� l �
improvement Perinit
A buiidin4 aermit cannot be issned with onlv an Imarovement Permit
New �/ Repair Add�ion Type of Strudure ,� Watec Supply ��I
# of Occuparrts #•of 8edroom�-7� 01her
Basement'1 �Basement F�? �_ . �
ba caoc_ '. ��
Prajeded Da�y. Flow: g.p.d Pennit V�td For �'Five Years 0 No Expiration
Proposed WastewaterSystemType: C'd•�v2s�iohA �
Pump Requined? Yes �_No
Proposed Repait : Ce n�,�.fr oit� � I /
Permit Cond�ians; � vs v�� �m �f��v,�erf lih es a���-�ro:�__ pu, �dih
G�
Owner o� Legal RepreseMative
Autho[Qed State Agecrt:
� ,�
u tidcl �r:o ,7 `
Date: �O� " �' ^D U
Oate: 1 i��!- o 0
The issuance of this pem�ii by the H�Ith Departrne�it `in no way guaranfiees the issuance af other p�rmits. The permit
holder is respa�sible for chedcing with . appropriate goveming bodi� in meetlng the� requiremenb. This siie is
subject to revocation if the sifie pian, plat, or the i�rtended use changas. The Improvement Pertnit shail not be
affected by a change in ownarship of the site. This pertnit is sub]ect bo campliance with tha provisions of the �
Laws and Rules for Sewage Treatmerrt and Disposal Systems of the North Caroilna Administrative Cude.
� Type of Was�ter System C:e�nv�rcha� Wastewater Flow:�
�J �/� 1�
Fac�lity TypeX Ur. �S ��1 �� New F�i Repair OExpansion �
8asemeM? 0 Yes �No Basement FaWres? Q Yas �(No
Wastswater Sv�tem Reauiremerrta
�
:Sept� Tanic Size• C�U gaqons Pwnp 7ank Siza: gaalions
Total Trenctt Ler�gth: r-�'�'�' fyee�t� Maximum Trend� Depth T� incttes AggregaGe Depth:� in.
Maximum Sal Cover. � ind�es Trench Separatian: g Feet an Center -
Other:
Permit Expiratton Date: �l -��/ � 0 S� �
Authorizad State Age� I�ate: 'f� �/ -db ,
The type of system pertnitted 0 doe9 � oes nct differ from the type specified on the application. 1 ac�pt
the speciftcations of this pemiit
Ovmer/Legal ReQresentative Slgnature• — Date: /oZ'' ��� •
PC1-IO, rev.11/18199
. _ __.__,.. _.. .. _.... _...._ _...__.._. .... . -- -
�P�rson Caunty Health. Department
- � E�evironmenfal Heaith Section T� Map �• .�- �-��
� Parcal #:
Si�'E S14ETCH _ . _. 33 �
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Subdi sioNSec�a ot#
�- ��00
Date � �
,4yst�t cam�o� represent appraur3n�te cnntuurs only. The cnntractar mrrstJlag ihe systan
� prior to b�nn� tlie installativa to insure that pmPergrade is ma�iit�ai�red
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Person County Health Department 330
/�.r� Environmental Health Sectio��n� ���
Tax Map #: � �I V Parcel #:
Zoning: Township: ���� l� r J cr
Subdivision: ��K���`� - C�4S Section: �V Lot: �� _
Applicant• �_ CC� ���1-(�����15 .
Locatiom l7GCFF J���d
Operation Permit
System Type (In Accordance With Table Va): �
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZATION. /1 _ n
� a3 -� 1
Date
Tax Map #: Parcel #:
PCHD, rev. 10/12/99
• PEFtSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE tAYOUT
T� ��: � �D � �� 3 Z�
Zoning ' Tawnsfitp Y[�� �/1/��''
��� �� YYJ IYJ 1�1 i"l6{ k.i �-r� hS .
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Tvqe of Water Supp1Y:
Reauirements:
Weli Permit '
�dividual Communiiy . Pubiic
Site Approved by ✓ _
Grouting Approved by ✓ �� -o �
Welt Log ✓ � —
Welt Ta � � �
Air Vent �
Hose Bib
Concrete Slab
Well Dtiller
Well Appro
.
w
�
Date. 0� o� 3 J C� �
**See �Attached Site Skefich**
Welts must be 10 feet from property lines.
Weils must be 100 feet from septic systems.
Wells must be ai least 25 feet from any building foundation.
Other conditions:
PCHD� rev. 11/Z9/99
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date: �/ �0�'
Owner. �'� � c�
Location/Directions:
Subdivision Name:
Drilling Contractor:
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Lot #
WELL CONSTRUCTION v
Distance from Nearest Properry Line ! c� Distance from Source of
Pollution t G a
Total.Dep.th:�_ Ft. Yield: O GPM Static Water Level QZ.r' Ft.
Water Bearing Zones: Depth ����t. F� F� Ft.
Casing: Depth: From 6 to��Ft. Diameter: Inches
TYPE: Steel - Galvanized Steel
IE 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 reason:
Grout: Type: Neat Sand/Cement / Coricrete
Annular Space Width � Inches � .
Water in Armular Space: Yes No
_ .. Method: Pumped - - Pressure Poured � - � � � �
Depth: Fr�m O to �20 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�Li1TY HEALTH DEPART .
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Sig ature of C tractor Da�c
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