A40 333t
;,{ � .
q � y�o
a,��: �a �
,�
a��,� �d: � t�- i.�o.00
B�� 9
c+�{° �3036
J
�
. 6� .
�`� � I � � -
U -� � T�Nmo�_ A- vo
� �,�� U
� �/ .
. � � p0 � ��.4� �� � ��+ �- �,s
�I' o�
Person Courriv Hesitfi De�artmet�t �G( 1°Z��-0 (
Enviro�mental Heaith Section � , � q �
_.:�� � t • `• ' '13:�1 �i�
1 •- • • •- -• �. � -�:��1 ' Y�� a • �■ •� 1 ''IL
� L�- �� 4 �� i - • � �� - �- � • 1 • - ► • • � • • i- 1 . _ • � _
�) � � Ml� (Owaedagentlproapec.liw ovmerj: �'�� .,-� � , .� i l � �� k : ns
• HOms Pt1o11� _,3�, �i -1_�i (� � • Ad� 4S�l�S.S F�l �a �� li rn: i� � R J,
Btniness Phone: � � • �w; R: : >,.,�.,
Z� Nams and address of eun�ecrt awner: �� ,.,,, �
3) Psopetty D�fptioc� Lot slxx . o Taws� �B_
D�ediorte t�o 1f1e P��Y ��9 coad nartt� ecld ntunbersk I.� 7; i rl D e k I.,, � r_
� Praposed Uss and 8truoturs Descriptian: anawec eacl� of the fo0owln9 qc�fons:
a1 � R�E�dst� ❑
b) Stirdc Buit q Modular q SMgle W(de Wide C�'
� Numbec ot 8edroarnx '� �b���� Nucnber af cca�panLs oc peopie to be secve� �
e) Baseme�rt Yea q No O�tf'yes. t6d�uax
• t� Garbage Oi�pOsa� Yes q Nc 0�
� 4in�aions of P�oQosad Strucxure: YVidth: � Dap� �2
���PPhI �YP� Pdvate q{new Q ac eodstin9 �� Pubite 4 C«mna�dY �. spdnq �.
Are arry w�aqs on a�oi�g property� Yes 0 No t�tf'yes, loc�ion
� Plase Indicab O�ed Sysbam TylPe: (syat�na can be rallosd in ord�M� Qf Y�' P�'�l
✓Coaventlorwl I�ociified Caev�atlonal _ Ai�tiv� �nnovative .
Otlw �:
CLEARLY. 3TAKE ALL CORNERS AND LINES OF THE PRO�TY.
STAKE THE CORNERS OF ALL PROP08ED STRUCTURES.
PI.EA�.4E ATfACtI SURVEY PU1T OR SRE PUW TO TH19 APPl1CA'iiON
I t�ebY maka s� to the Pe�soo C�u�ty Health Departmerd ior a a#a evabustlon tor the arsite sawaqa mapa�l SYs�cn
tha abovadeacribed property. t agree tl�at �e cflnLents of this appYcatlon are ttue and rept� fhe rt�dRum fa�tl�a bo
piec.ed on the �ty. 1�� ttls s�e is altered a� the W�d uis ct�ac�pes. !he penn� shaO become inva�d. l�S�
that as ap� I am c+espon�e far iden�ijring and rtmridn9 W'c�tY lhees, co�nes� and ittaking the sibe �mbie foc
pecsonnd of the Per�on County Hea�h Department to cartdud tt�r evaG�llons. l ta�and that 1 am t� ��
H�ith D !f my pt+o������ any wetlands as dai�0ed bY ��1l ���g�.
/�-�C-o�
t.�al Re�xeaentative . p�
�
May-29-01 10:08A
i� M�� ___.��� aa�w �
aPauc+nt
�rn
� ��'?�' R
P.02
PEdRSON COUNTY' ENVIRONMENTAL W AlLi�i
rw w� ■w• w�w.. ...... �.��' ---- -------
e�- .�,_
. � �,� �t,�,tAr_,,,,_,.L. S
� .
Im�prov�tr�nt permit
,
t�1aw ��Additlon Type of Stsuauro C� �P.�,v�� �, �
� of Cxcupar�t�,�►"�• # ot �edrooms � Otrisr
ProleGtad Da�r Fiow: g.�.d. PertnH Y�kd �'er. �ive Yeors C� No
Proposed Wsadewatw �'_4r ve h't � ar��
Proposed R�pair. Gr� r� ✓ e `
- -oh�
S US
Owner or Lp�! Raprossna�tive
AutAotized Stal� Aqent:
lft� �j � /L�.�.
Was�r Suppiy��,.4._��` I
_ �. , Systsrn Type�
/ �
r0 „�H.
z'7vGr.�.
c�.t�_`_,,,7 ' ( �a ____
Qslt�:_,,,._.�.�L.�_
Tha iesuano� of 8�is p�rmti by the Msnith C��r3er�ant�o wey guara+�tQ�s tttie i�suanw at otner psrmi3s. T'he perrn'r! halder i$
responaible tor dteckinq wwithh �PP�P� �1ov�r�nq bod(es i� rn�attn� ttu9ir roquiroms�ta. 7'hi� �ibn la subj�ct to rivvc�.stl�n ii
th� +eile pfan, piat� or tta lnborldW uw cl��gs�. Th0 im�v�ssnent P�rmit shall nat be afh�KeC by a af�sn�e in �aw�u►mhip
of tM siba. This p�rmft Is s�,bjsat to campli�noea vwith tfi� provisFons d!!�e Laws and R�Mx� br rww�aQa Trwlmant and
Qiaposal 3ys�ms or t!w kot3h �mrolirq AdminEstrativa C.ods.
Wastewater Systam
�'`�.,,,�, Waetewets� Fbw: �� v p.p.d. Type: �-6j��
��
FacNity Osssrip�on, �S , �// New � Reprir O Exp�n�ion 0
Basemertt? O Yea No Basomerd �'rxtures? 0 Yes P3o
iruNt�r
Tanlcsqo: &eptic Tmk sizn �00 ��3. Pump T4nk s¢s `-'"'- gal. Gresae Trap airs �� gal.
Trsnch�: 'Cetal {enQth �v_ R. in►nch xNidth _„_,�„�R. iotal A+b� sq. tt.
Mair. Trortch Depth: � in. A9Si�'WY1� �P�:_�.,..�'�in. 80� Cov�r. � irt. Trench Sep�ralior. �t't. on cantar
Perrrtit E�itatlo� �at�: 6
Autl�ortzsd State .4gent Dotu: � � �
"tie� �lt�cha�! sib� pba and r�dcfert�dur�s �ag�ss fvr a wsai pr�k oa�dlt�ar+�.
?1» tYp� o/ sysbrn PptnKbad a�S � d difT�er frvm ttw typo sp�s0lDod on !ho spp�catbn. 1 aaaipt N►s
:pacFPlca4ionut of tlti� p��nil.
o�,���, ��.� �„m: a.�,; _4 -� �
o�� ��
Systsm iype (in s�ance wRh Tab�s Va)
ihb syst,o�n I�s bMn �qed i� c�rt�pifsneo w�7► ap�l8c�fe Nocth Carulh� Qen�rr,� St�ulss� i$ws +nd Ru!rs fbr 3vwa� T�enant
wrsr�e fd�a! M� � Ca�ditlqne of tM M�prov�ret Pain�dt ss�d Cvnstrucddn Aul�prua�on, Issusmcv ot illi� perte�iit Impli�s no
;r�n R+s�sr�ed win ria�caan �nop�xty �ar u�y gh,a, p�od c* �n.,
�_�_
Authonzsd Stats A�enf � — —'-
PGHO, ray, G'3/071f11
n�dy-�z9-oi io:osa R.o�;
t
A�plk�ttion #: �"7 �
T�uc MaF �: 333
Parcal #:
Person County Health Department
Erivironmenta! Heaith Section
S1`�E SKE7CH
�yw,ti,,z u� �Gt l�c!l �c� i� 12�5
/1 pli ' , arne Subdlvista eCtiohll.ot# �
� 7�0(
AUtharized State nt Date
Systcrrn compo�er:ts nprucnt a�protxlntatt cnntours aRly. 77se coxttattvr must, jlag the s��yisnt
arlor ta 5r�i�nirrQ the lristallati�n tr� fnsure that v�Uaer vark is mulntaLred
�/ �
scaae; / � S�
!'CtiD. rov. 9�112t98
PERSON COUNTY EiNVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE �LAYOUT
Tax Nap#: �- �� �� 3 z �
Zoning
Tcwnahip / `��� �Pi%
pPp�kan� ✓Q i%1 /�? Li � Gt/K 1 it..$� .
r. . i _ �
Loutlon: �
k-
��� � �• Sectlon: �-O� 7 �
Subdivblon: .
Tvqe of Water Supp1Y:
Reauirements•
Weil Permit
�dividual Communify . Public
Site Approved by
Grouting Approv d y ✓ �
Well Log ✓
Well Tag � �
Air Vent � �
Hose Bib
Concrete Stab _
Weil Driller: �I�IX,t���
Welt Approved By:d��l�
�
�J� -�t
� ���
.
Date:�� -"(� l
**See Attached Site Sketch�""`
Welis must be 10 feet from property lines. �� rG s,�en�
�p w��( 4v ►�� . .��.- �� 1� �
Wells must be at least 25 feet from any building foundatio�.
Other conditions:
;:
�
� PCHD, rev. 11/29/99
e
�
Z� --
PERSON COUNTY ENVIRONMENTAL HEALTH � �
::
WELL LOG �
Date: s3-/o-D�' '
Owner. ��,���_� � ��� � � SR# ' � � �
Location/Directions:
Subdivision Name:
Drilling Conbractor:
Lot #
WELL CONSTRUCTION V
Distance from Nearest Properry Line J v Distance from Source of
Pollution ( G a
Total.Dep.th: l�A� Ft. Yield: �.5� GPM Static Water Level a?.5—' Ft.
Water Bearing Zones: Depth // : t. � F� F� �t.
Casin : De� th: From 6 t—��o�0 Ft. Diameter: Inches
� r
TYPE: Steel - Galvanized Steel
If Steel, does owner approve: Y�s No
� � Weight� � Thickness:� '� Height� Atiove 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 Armular Space: Yes No
_ .. Method: Pumped � - - Pr�ssure � � Poured � - � � � �
Depth: From O to �� Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag_lbs.
-=<Zf mixtuie (sand, gravel; cuttings) - Ratio: to
'� ID Plates: Yes � No � � � �
� 4 x 4 slab Yes � No
DRILLING LOG �
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�vi�TY HEALTH DEPARTM NT.
(� _-01_
Si nature of ntractor Datc
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
.. �
N
a
Date: . �- -�i '
Owner. � SR# ' � �
. �r ..
Locatiin/Directi�ns:
Subdivision �Name: p��'r ' � : � � Lot #��
_ _
Drilling Contractor: � � ��
WELL CONSTRUCTION
Distance from Nearest Properry Line � v Distance from Source of
Pollution ( G �
Total.Dep.th: Ft. Yield: GPM Static Water Level a2.r' Ft.
Water Bearing Zones: Depth 'P IFc. � F� F� Ft.
Casing: Depth: From 6 to�,g._Ft. Diameter: Inches
TYPE: Steel - Galvanized Steel
If Steel, does owner approve: Y�s No
� � Weigh� � Thickness:�. '� Height�Above Ground: I�i Inches
Drive Shoe: Yes ✓ No . �
i
Were Problems Encountered in Setting the Casing? Yes No � �
If "yes" gi� e r�ason:
Grout: Type: Neat Sand/Cement / Concrete
Annular. Space Width � Inches �
Water in Annular Space: Yes No
_ .. Me.thod: Pumped � - Pr�ssure � Poured � - - � �
Depth: Fr�m O to �2 � Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag lbs.
If mixtuje (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes � No � �
� 4 x 4 slab Yes � No
I HEREBY CERTIFY THAT THE ABOVE INFORMr�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C�Li�TY HEALTH DEPARTM .
C.% -��
�- _ .�
Sig . turc of Co ractor Dat�
„ � � .
v-,-�--,. '' '
- • -- . _ ' I�10rti1 Carolir�a�. ' .' =-
.. -.. .. Departm�nt of Environment and Natural R�so�rces
Diviaion of Riate�c 9uatity
Groundwater Section
P.O. Box 29578 - Rateigh. N.C. 27626-0578
1, WELL LOCATION:
2. OW�ER
3. ADDR�S:
on badt oTfori
Cotinty
4. 'i'OPOGRAPHY : �raw. slope. hilltap. va11eY•G�
Da?E: ��i-U
5. USE QF Vl'ELL: � - - ,
� �� DIAMETER �
6. T'OT: �I. DSP'1'Ii: .
7, t;.3SING RE.'V[OVED.
. IS�:
�� -
8. SEAL:NG MA"IEFttRL:
�a� c�mc_
5ags of cement ,_
ga1a. of water �_
4S�rs
�rype niacerfa!
c9�.� �ement
�ags of cemen: ,___..
yds. of 9a.zd ._._--
g2tts. of water
9. E?�t1t.t METfiOD E1�iPL�►CEMEN'P OF :litATERIAL.
�
quaciraaglt No.
,t. D[AGRAM: Draw a detailed ekecch of.
well ahawinS total depth. dcpth and dia-
er of screeaa remair�sng ia the weil. grdvei
Nai. inte:vdls of casing perfaraaoas, ana
ths and types of Sll aiattrials v�ed.
,r
I do biereby ctrtitY that this well abandoncAent recocd ls true aud ex�ct.
Date � � �� � � -
Sig,n�aa�re of Coatia� �
WELL LOCATION: Draw a locattoa sketch on the reverse o tii3.s sheti. shaurir$ the ritrcc-
tion and distauce of the well to at ?east two l2] nearby �� Stat�e b
suCh as rvads. intezstctians as�d streams. Identlfy roads �8h
way mad idantl8catioa ncuai�era.
Submit origtnai tv the Divisioa of Water 9uallty, oae copy to the Driller.
and one copy to the evvaer.
GW-30 Revi�ed I /98
r
�
Appiication #::
Tax Map #: �
� Parcel #: �3��
Person County Heaith Departrnent
Environmentai Health Section
SITE SKETCH
�e,t-�G• �.rnLf�L � K�i �1 c. R�r�s �"
Applica 's Name Su division/SectiaNLot#
�
- � aa -� !
Authorized State Agent Date �
Svstem components represent approximate cnntaurs only. The contractar mustJlag the system
in beginning 1he installatinn to insure that proper �rade fs ma�ntainer�
,- e.
�A� `
�d ��
i
K�cP Wcl� 3i�� �irt�m ��+nc�c�«K
�(15t�.1( �.5 S�DWn l,J�-ll 111arKcd
tJ-� cP-t,ic. (Y�a� Kc � c�J / L c` m c. F(�-5 5,
I rr=�p�
Scale:
3 ('��uC ����s
PCHD, rev. '! 0/12J99
. � ��rs�n ��uaaty �� �3eQaetmerai
�.�avi�nrnerstal �3eaith Section
����: �� _ �� '��3 33
�
Zsaning: - Toumai�i� • . .
Subdivlsio� � �/'�� Seciton: __; l.o� �
�►4P�� '
�o�: i�u � R� - J - � . .
� �pe��aii�n P�ermit „
��� System Type (1n Acxardance Wi�h Tabie Va): �
THIS SYSTE�YI HAS 8E�1 INSTALLE� IN GOMP�JANCE WITH AP�UCABLE NORT'H�
CAROLIN�►1 GEi+IIERAL SiATUTES, RULES F�R S�IIIAGE TREATBAE�►IT AND DISPOSAL,
.AND � ALL CONDITIONS OF THE 1MPROYE�AEiNT PE�1T � AND C�NSTRUCTtoN
AUTHORIZA N. � �
� . � r�l�� � . � ��1� �
� or¢�d State Agent � �
�l'i
� � �0��, �Lcr .�� �c
,� � 7 3
z `i'7u ,�,7 �►
�'a r ., �,
�`��
� ��
��
� � �.
��
b�
. ���
. ��
�
. ����—� o
� ��
�`�i� 1 ��
`3`'
�2<<
�(`3 rr � .
�< « _ ��������
��3�; ty`�v �f L
5 r3 cr o2 � t7� IlL
�
�. ''
.. � � PCND, rev. 10/'t 2J99 .
PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map �: � � � Parcel # v "" �
Zoning
Townahlp ��Ct� 1�-( l� L �
ppplicanx
[Q�. i-�b. ba� � c-�;-�i
Location•
b L}. �
Subdivislon: ��(� L�C fC,$ g�on: Lot _1--
Well Permit '
Tvae of Water Suppiv:
v Individual Community Pubiic
Reauirements•
Site Approved by ✓ "
Grouting Approved by ✓ ,
Well Log ✓
Well Tag ✓
Air Vent �� ���� �
Hose Bib _.
Concrete Slab
Weli Driller: � � ����
Well Approved By: ���v� �
Date• �'" C�-�a �
**See Attached Site Sketch**
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be �at least 25 feet from any building foundation.
Other conditions: �n5�1� �..s 5���'^ a n.�Kc{c�
l�M O�� W�(� DU�-`�� C�h��D�lna�c./ �i �� W�Ctmc�.�
P p
PCHD, rev. 11/29/99