A40 3310
.
Tax lllap i� T I`T� Pa�td f �� d� b 3 3�
Zoniog Tawns6lp ��a.t' � (Ziv c,r ���
n�,�,,,� SS'q�n.� E-Ic�,�,,l���s - ..
Loeatloir � � 1 � �A � 1�-� n� • c�i � ('t In �� '�
su6dwlsioa �C H��s s.dio� - Lat �f-3 .
Improveme�t Pennit
A buildin4 permit cannot be issued with onlv an Imarovement Permit
New '� Repair AddI�on Type of Strudure � Water Suppiy l•�e �
� of Oxuparrts �•of 8edrooms T Other
Basemerrt? ��, Basemetrt Fbct�u+es�� -
Projeded Daily. Flow: �.� g.p.d Pertnit Vaiid Fa: �e Years 0 No Expiratia�
� Proposed Wastewater System Type: G'b� v�,stf�b,. c/
Pump Requi�ed7 �'Yes �/. No
Proposed Repsit: C'onven rbna / n �
Permit CondiHons: E'e0 SNS�u° n' S� -�reh. bu��o��:ee 1-�u..cia�'or. , cr n.o� ��� -
s �Zn wc as� ��
Owner o� Legal Represernative
Authorized State Agecrt:
Date: d
Date• I/- o� / -Ov
The issuance of this peanit by the H�Ith Departit(ent in no wey gemrantees the issuance of other p�rnits. The permit
holder is �espansble for chedcing wifh . appropriate goveming bodtes in meetlng thek requirements. This site is
subject to revocatlon if the site plan, piat, or the trrte�ded use changes. The Improvement Permit shali not be
affecbad by a change in ovmership of the site. This peRnit is subject to campiiance with the provisions of the�
Laws and Rules fo� Sewage Treatmerrt and Dispagal Sysboms oi ffie North Caroiina Administrative Code.
Autho�ization To Construct Wastewater Svstem (Revuired for Buiidina Pecmitl
� Type of Wastewater System ��vu+. ronal Wastewater Flow: g(� .p.d.
Fac�7ity Type: /3r. A� j��e-� Neu� RapairOExpansion 0
Basement? 0 Yes No Basement Fnchues? Q Ye� No
Wastewater Svstem Reauiramerrts ' • -
:SepNc Tantcc Size: 1�d�0 gaitons Pump Tank Size: ''� gallons
Total Trend� Length: �0 teet Ma�dmum Tre�d� Deptk � ind�es A99r�a�e Depth: �a in-
Maximum Sa'1 Cover. � ind�es Trench Separation: '� �� Feet on Center _
Other:
Permii ExpiratIon Date: 1/-�� �"D S .
P�uthom.ed State Agec� C�G�t.� Uate: ' f!-- a 1- (7C� .
The type of system permitted 0 does � oes ot differ fro the type spedfled on the appiication. 1 acr�pt
the apeciftcations of this pemiit �
Ovmer/LegalRepresentativeSignature: Dafie: `�' oj •
" , PCtiD, rev.11/18/99
Tax l�ap �: � �-1 �
Zaning .
APPitant J� nC.++� �-�
�.oatloi� 1 �{ � � � �.Gi K �
Patesl �
Tarmship 1�I(Jl,� �jV �i'� �.
subdtvbica: �G' H��s S.dlo� - Lot `f'"3 .
Imaroveme�t Pe�rnit
A buiidinq aermit cannot be issued witt� onlv an Imarovement Permit
New � Repair Add�Ion Type of Strudtue l��
# of oa�parus _ �-of Bedrooms ✓�' Other
Basemerrt? �� � Basetnent Fixhues? ci
ProJec�ed Da�ly. Fiow: 3laDg.p.d.
. Proposed Wastewater System �'YF
Pump Requited? �'Yes �/.'
ProQosed Regsic: C�anven rbHa
Petmit Ccnddicns: eeo Sys�e:
�tCin v�t us-� ��
Owner o� Legal Represerrtative
Authorized State Agec�t:
Pertsui V�id Far. �e Years
water s�py I. �e G
0 No ExpiraBoa
/C j _
!ii
Date: i'
Date: I/- d / Ov
The issuancs cf this perm� by the He�tt Depa�h(ent in no way guarantees the issuance of otfier p�rmits. The permit
holder is tespo�'bie fo� d�tedcing wiih.appropriate goveming hodies in meedng the� raquirements. Thls sifie is
subject to revvcation if the sIbe plan, �lat, or the icrtended use changes. The Improvemecrt Permit shatl not be
affecLed by a ct�ange in ovmarship oi the siie. This permit is subject to complianca with the provistons of the�
Laws and Rules fo� Sewage Tc+eaht�e�rt and Disposal Systems of ffie No�tfi CaroMa Adminlstrative Ccde..
Authorization To Construct Wastewater Svstem (Reauired for Buiiding Permit)
! Type oiWas�waier System �r�vu+. �dju+,l Wastewater Elow: Gil� .p.d.
Fac�l TYPe: /�r � � "' t� Ne�,�° Repair�c�sian p
Basement? 0 Yes No Basement Fodcues? Q Ye� Nto
Wastewater System Reauiremer�
:Septic Tank Size• IDO�'J gapons Pump Tank Size: '� ga�Ons
Tctal Ttendt Leitgth: � feet Ma�dmum Trienctt Depttx � tr�fies Aggregabe Deptt�: /� in,
Ma�drttum SoU Cover: � ind�es Tremh Sep�aration: ..� Feet on Canter _
.
O�er:
PeRnit Expiratlort Oate• 1!�� ��"D 5' .
Authodzed State Agec� ��-�c.�� (��; • /-,2J - c,'�C) .
The type oi system permitbed . C1 does � oes ot differ fro the type specifled ort the appUcatIon. 1 acrx�pt
the spedflcattot�s of thia permit �
, Ownet/l.egal Represe�tative Signat�u�e: ' ' Date• `� oJ .
�. , PCl-iD, tEv.11/'18/99
_ ._._..__,.. _. _ .._.. __....._ __.._.._._. _._ _ _ --
• � Person County Health. Department
�'�` � � Environmental Healfih 3ection T� Mep �• A" Ll"o
_ _ Parcel #: _-- � .
-- ---Stf �r►n. � �al w�Crr,s
A pilcant's Name
. Authorized S te Agent
SITE S14ETCH
�a�� �f.�f3
Subdi ision/SectioNLot#
��- a-I -o v
� Date
System compane�s represent appraudmate cantours only. The conhactor must Jlag the system �
prior to begin� tlie �nslallalinn to insure that prqper grade is malntained
� , ��� �� `���' �
scale: _l ` � �o' _
_ _ ._..__ _._ ... _ ._...--�-..._ _..._..._._. .... _. _.. .
- • � Person Caunty Health. Department
' � � Environmental Heaifih Section
. wnw� w�irT/'�U
Tax Map #: . �l' Liv
Parcal #:
_ . .__S�•r►^� � %�aw�r,,s � �a�-i � ,i� Lc�f.�{3
A pllcant's Name Subdi isioNSectiuNLoi#
. 1 �_ �-I _o �
. Authorized S te Agent Date �
Sy�ent congwne� represent appraudnw[e contorirs only. The contractor must, flag the system �
pr�or to begin� the instarllation io infure that prqPer grade is ma�ietained
�� , �-�W .
. ti�� �
sca�e• 1 ` � `f� '
Person Gounfij 9�ealth Departme�t
'1 Envirvnmental i;ealth Sec#ion 3 3)
Tax Map #: �`t� ParcEi #: ��
Zoning: Township: �` �`'i.- ��"'�
Subdivision: ' eS Section: Lot: �3
Appiicant•
Location: � ��� � �.'(.�.1� �
Operation Permit
System Type (In Accordance With Tabie Va): �
THIS SYSTEM HAS BEEN INSTALLED IN COMPUANCE WITH APPLlCABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTiON
� :AUTHORIZATION. � . .
,
�
jl -1 �- 1
� ,.,..
�� �
.s�
a
State.
/�'���'� �
Date
7� �-
� �• �.
,�-' ✓ �. �
Tax Map #: Parcel #•
�w ►,"
PCHD, rev. 10/12199
���, �� ���� ��
`--- = � � ��� �-
���.�.��..,,�,-,����.�. ���.�.�.
WE�L PE�t�NIIT�
3� - �
Tax Map #: � o�f'J Parcel #� Township
gPp�� v� �:��,� �. U�.�,
Searon: I.n� �
. Locations � " �
✓ ' Public
Ty�e of Water Su��lv: Inchvidual Communitp
Requirements:
Site Appsoved by
Grow- - -- � � .,. _ .
Well ]
Well'
Air V
Hose
Conc
'�°5ee Au�ched Site Sketch"�
Wells must be 10 feet from property' lines.
Wells must be 100 feet from septic systems.
WeIls must be at least 25 feet from auy bu�dittg fouadation.
Other conditions-
�
PC�ID, rev. 09/07/01
PERSON COUNTY ENVIRONMEPITAL HEALTH
WELL LOG
Date: - � - �� �
Owner. oy �%�����
Location/Directions:
SR#
Subdivision �Name: __ !J�-�'�% ' c Lot # /a 3
Drilling Contractor: ' � ��
WELL CONSTRUCTION
Distance from Nearest Properry Line / c) Distance from Source of
Pollution t G a
Tocal_D�.rh: t o a FG Yield: � GPM Static Water Level Q2.S—' Ft.
Water Bearing Zones: Depth �s�F[. �°___/,�� ��. �� . t� Ft.
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" gi� e reason; �
Grout: Type: Neat Sand/Cement / Concrete
Annular. Space Width � Inches
Water in Am�ular Space: Yes No
_ .. Method: Pumped � - Pressure � Poured � - �
Depth: Fr�m O to �,20 Fc.
Materials Used: No. Bags Portland Cement Weight of .1 bag lbs.
If mixtule (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes � No �
� 4 x 4 slab Yes i No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH R GULATIONS SET
FORTH BY�THE PERSON C^vLi1TY HEALTH DEPARTMF_,�JT,�
� L U�1"� ��1�"0�
of Cont or D1ic
►.
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