A40 332. 30 O1 11:15a FREEDOM HOMES\
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Petson CaunN Haatth D���rtment
Envlronmentsl Heai{,h Ssction
APPUCAI'fOAI FOR SERVICES
3365975822 p.2
P.O1
Tax �: �
a��f �• �� 3`�--
IF TME INFORMATIOH IN YHE APPLICATION FOR AN �ROVEMEHT P�RMff tS PALSiF1ED CHJ►Ii�,ED OR THE SITE lS
ALTER£D THEN TNE IMPROVEINENT PERlNI� AND AlJTHORt?ATIOM TO CQNSTRUCT SMALL BECOME INV�ID
t} Psrmitlsqitaslsd by: (Owrurhgsnttprosp�ctivs owneh: ��� � "`QS
HomePhone• Addresa:_��e�-IAtH .f►
euatr�a Pt�one. = F' � , nx � r� N c .� 7 s-r
2) Namo and addtsas of cunrent owner. �.� d W�C,1-. j
�v r'� t J+�, r
�) Propsrt�r De�icNptbn: tw �: To�w�.nip: fi R'u�R r
Oksabns to the P��Y tlndud'mg �ad rtemea a�xf nuaM¢rs): �Jr 7° r�af ."veC L�� ac� �(�1� IC' ly��
r-as i ti,r- l h: ib R c� v�'1fl ` � r r► � i� CY L�Q K, iJ1, �:'D( tC J
;T4 w� �i n 2 t e�
4) Propossd ur� aew Strvcture Deseription: answer ea�h of the kqowing qvesiions:
a) Propoaedyl. Exiatin9 a
by Stidc Bufit f�. Moduler q irg{� W�de U. Douhle Widejli
c) Numher of 8edrooms: � Numbsr of oowpants or peoplt te be senrecl:
ef �(; Yes ❑, t� if yae, � ot �semerH 5xtures:
!? � Oispo�al: Yes 0. No +7
9I dane�ufons of Ptoposet} Structure� 41Adth: � OePth: �
Sy Wstor Supply Typs: Privale�(r�ev�or e�dstlrsg �. Pub[ic [�, Communiiy f7. Spri�D o
Are any wNis on adjoining proparty? Yes n Mo u tt yes, lor.afion
s) Paaae Indkata Oeoi�ed Systam Type: (eystar►rs can be rtnkod � order at your prsference�
�ComertHon�! Modifled Conva�tonat _ Altomative �IrmovaHvs
,�� Oth�r (sp6C11jt):
Ctf�1RL1/ STAKE ALL CORNER9 AND L1NES OF THE PROPERTY.
STAKL THE CORN�RS OF ALL PROPOSEO STRUCTURES.
PLEASE ATTAC}f $IfRVEY p�p7 OR SITE PLAN TO THiS APPUCATION I
I htKBby meke appiic¢flon to the Peraon Courriy Health Department tor a site evaluation far the on-site sewage dispasal sysiem tor
the abn,r�deecsihed prepeqy, � a�� �t � p�tants of this �plication aro trve and r�pre�ent lha maximum (aciit{es to Oe
pleced on the properry. I underste�d if ihe site ia �dtered ar the tMended ure chsngec. U�e pennd shalt become irnalid. l understan0
tl�at aa appltcanl. ! am respotLtible {or id�d�t9 and markin9 Property Ilnes, comers and makMg the a+ta accessibi� for the
peraonrre! af tfte Per9on Counry Hoaith Depsrtmpnt to condue� d�air ev�wtior►e. � urtdetstand Mat 1 am responsible for rfotifying the
HeaRh artmeM if rtrv propeRy cantama any wetlands as deaignated by the Armyr Corps of �'ngineers,
. �1 (\
Ll , `_�.1 �
Owrter er Lega1 Re mih,e �
PC}iQ. rw. 14tt�/49
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. ��yi.'��a sC y�'� ����tl��" ���� ��� �ltl�' � yY 7 � �. i ��.J 1
.� � . �+,� � 327 �
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T�xse of 91Va�r Su�s�iv_:
��UII'@fT1�f9tS:
lAlell Permii
�ndividual �, Cammuniiy Pubiic
Siie Approved byi /2zQ� l� �9-0�
Grouting P+PProved by . C.�S r�- 2►-�
Weli Log � r�- z�-� �
Weil Tag,i �?�� ►� -a�-o � —
Air Ver�t' �-�-� �� - a� , o � _
Hose Bi�%'j� i � r��'-o i
' COnG7E�E Si�7i � ►� -z9-o/.
�/@Q D�'9ue!':�c�(��'�C� �l��4�� �.,-.��.
. . .. �
We�l -�lpprmve� By: - �,� .
. ,,d _ c,,,.�.� �
�ate: i�-a�i-o�
**See Ai#aclaeci Si�+a Si�tc�h'`*
UVelis musi be 1 Q fieet from proQerty W�es. .
1J1�ells must be 100 fiee# from septic syste�ns.
Wells must be �at leasi 25 �eei from any bu�ding foundation.
Other cx�ndi�ons: _ �
FCtiD, rev 11/29I98
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Tax Nap 4k
�
PERSON COUNTY ENVIRONMENTAL MEALTH
�1.
�� Towoship
p,�ppp� ��4 Yn P�.,�y I'7A w k--! � s
L�oatloi�. �ii%ri�Gf �a � ' � ' ���_
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3ubd�o� 4. �' \ / 1'�' � s.enoee � � � .
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v� ��.�o6,slS
Imaroveme�t Perinit ��
A buitdina aermit cannot be issued with oniv an Imarovement Permit
New `� Repair Add�ton Type of Stcucfure � Water Supply,ill�� � .
# of OxuQaMs . �•of B� :� Ofher
Basemer�t? � Basemerrt F'bdu�+es? ��
Pr�ojec�ad D�►- Fbw: _
Proposed Wsstewatat
Pump Reqtmed?
Proposed Repair :�
Permit Catdd�ons•
�!�)�0�"�N �1�5 �97�'1�1
T—T�
Owner o� Legal Represerrtat�re
Autt�o�ed statie Ager�
Vatld Fvt: �i Five Years
��
�f�
❑ No Expiratlon .
-� u..d��t�C � �. � Kd �a � �6 � �
�a n�wl'• .
DSte: r
oat�: r� �- a./—ar�
The issuacx:e of this permit by the H�h Depa�ment in rm way gcmra� the issuance af other p�nnits. The permit
hoider is tespa�e for cttedcfi9 �. aRP�P� 9aveming � in meetlng ihei� requiremerrts. This site b
subject to revoc�tion if the stbe pian, plat, or the icrtet�ded use chartgas. The Improvement Permit shail rtot be
affecLed by a ctsange in ov+merahip of the site. This pertnit is subjsct to compliance with tt�e provisio� of the-
Laws and Rvles for Sewage Treatment and Disposat Syatiems oi the Nottt� CaroMa Administrative Code.
� Type of Sysbem (.o� v2�t,"�1ono,� Wa�raber Flow; �,p.d.
Fac�iy Typ ,� %'Ws� O► �� !' � New� RePatr 06�sion 0
8asement? 0 Yes o Hase�nent F�� Q Yes j$�No
Wastev�rater Sy�tem Reauiremet�
:Septic Tank S'¢e: �Dv ga4ons Pump Tank Size; ganons
Total Trench Length: � i�eet Maximum T�ench Depttx �� iru�es Aggreg�e Depth: �� fi.
Maximum Soil Cover: � ind�es Tre�ch Separa�on: � Feet an Canter -
Other: •
Pertnii Expiration Date• '": v� ' 6�� .
Authorized State AgenC DaGe: �1- a'% • c n � .
The type ot system pertt�itbed � does � � es not differ irom the Lype spedfled on ttte applicatior�. I accept
the apeci8cattons of thb perni[t .�"
Ovmer/Legal ReQr�e�tive Slgnature. v� . �ata� �����%��I
. ��T�T—
PCND, nw.11l18199
f
, __ __-----.. _. ._..._.___._ .._ _ ._.___. .._ _. _. . .
4 Person County Health. Departrnent
� Environmental Health Section T�x Map �• �" �°
PerC91 #: .� Z�
� SITE S�ETCH --
_ _ . _ . � . -_ _ --�, r,.s � a �-: �� � �.
�a m- N
Applicarrt's Name Subd ision/Se 'on/Lof#
� (r-al-ba
. Authorized St Agent Date �
,4yatem compone�r npresent approxlmate cnntours only. The coatractor mustJlag the systeni
� prior to be� the inslallation to insure that proper �rade is malntuined
Scale: ) r = y'0 �
�v; l� a �� L�,.
s�` �/w
50' �
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aS�X bo�/ �5�
%8; ; l-IOrxQ�
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5ef--4-ac.�// no C�ose/� y�CK S'
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Person County Health Department
1f, Environmental Heaith Section n
Tax Map #: �`( � Parcel #: J� 02
Zoning: Township: '� �' � � V�
Subdivision: �. ' CS Section: Lot: �_
Applicant: � �
Location: rit.�.��G� �� 2 �i + �GQ �-�. �/�%
�per�tion Permit
System Type (In Accordance With Table Va): -�
THIS SYSTEM HAS BE�N INSTALLED IN COMPLlANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZATION.
ll-Ig-al
A thorized State ent Date .
✓�- /�- /�--
`'l�qlol
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/� �-- /�_ �
Tax Map #: Parcel #:
PCHD, rev. 10/1?199
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date:...�' I-�-c�� '
��
Owner. � •� {s�
Location/Directions: _
SR#
Subdivision Name: __ ��6�i%u�' -�c�,��ca'< Lot # �-r'N
Drilling Contractor: � � ��
WELL CONSTRUC'I'ION
Distance from Nearest Properry Line ! c) Distance from Source of
Pollution t G a
Total.Dep.th: Fc. Yield: GPM Static Water Level Q?.S" Ft.
Water Bearing Zones: Depth 1�,�'�F[.9S �fF�.��'��F� Ft.
Casing: Depth: From 6 to � 3 Ft. Diameter: Inches
TYPE: Steel - Galvanized Steel
If Steel, does owner approve: Yes No
� � Weigh� Thickness:� '� Height Above Ground: /�/ Inches
Drive Shoe: Yes ✓ No .
Were Problems Encoun[ered in Setting the Casing? Yes No �
If "yes" give r�ason:
Grout: Type: Neat Sand/Cement / Concrete
Annular Space Width - Inches
Water in Annular Space: Yes No
Method: Pumped � - Pr:ssure � Poured
Depth: Fr�m O to � d Ft.
Materials Used: No. Bags Portland Cement
i
Weight of .1 bag l�bs.
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 PERSO�I C^v`vi�TY HEALTH DEPART E .
�/_
ig aturc of C ntractor Dac�
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