A40 335�' -� 7-�0
Aoonaao� oate• . ,
Amount P�id: Q .0 0
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Person Caurrtv Hesith Deaarbneet
Environmentai Heaitl� 3ectlon
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IF TNE INFORMATION IN THE APPUCATION FaR •AN IMPROVEiIiEHT PERMIT IS FAL91Fl�. CHANGED OR THE SiTE �g
ALTERED THEN THE IMPROVEiV1EidT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID
7� P�� �"7 • I�MfL101ia�i0ap6C�. VO CWfl�: _.�Ct m m cn �o a ��C : r� 5
I-lOrtis Pt�o�e: _.�b LI - 2�5 � � • Aid� ,S `1 �S 1�4 . //. m: �IS /�o(.
Bli�tOSS �]Ot1� �� ' fi � i, n r r�
Z� Name and addcess of currertt owner: .�a m f
3) PrcRacty D�scriQtion: Lotstax I. S9 Tawatd� �
Diro�ts ta the ProP�Y ��9 r,aad tmma and
� Ptoposed Uae and Structurs Doacriptlan: anawet each of thn fo0owin9 qu�ona:
a1 P�i�oaed �' 6dstlng 0
b) Stirdc Bu� q Moduiar �. Wkte 4 Doubie Wide �
c
c� Nu�nbe�r ot eedroomx 't T. R.13-0' � Number of ocapanLs. or p�la m
e) 9a� Yea Q No t�`�yes, � of besemectt f6ducax
� i� Garbaqa Oiaposa� Yes Q No CsY'
� Oh�ioc�s�cf Proposed Strtx�ue: VVidth: � Dapt� 6 0
be secve� 1'
� Wats! s�PPht �= Prlvate q(�ew Q ac eodatin9 �� Pub6c 4 Commn�dY o. SprinQ �.
Ars any w�eqa on a�o�ing prope�i�? Yes 0 No l9-ttyes, loc�ion
� Plasf Indtcab D�sli ad SyaLam TYPe: (sya� can be raaia�d In ord� of Y� P�'�l
�Convecttlonal Yodifted C�anv�ionat _ Al�tntlty� �nnovative
O�c (sp�dfy):
CLEARLY STAKE ALL CORNERS AND UNES OF THE PROP9tT1f.
3TAKE THE CORNERS OF ALL PROP08ED STRUCTUFiES.
PLEASE ATTACH SURVEY PU1T OR SRE PLAN TO'tHIS APP�ICATION
I hetebY maka �n to the Pe�on Camty Heatth 0� iia a a�e evak�tlOn ibr the on-sifie saMavqe dispo� syatem
ths ebove�esaibed �u+opetty. t agree tlmt the �b of this appY�tlon ats Vt:e and r� the mmortwm faa'itlea bo
p�ecsd an the pc+opetiy. l tu�at�d � the s�s is alte� or the &�ed u� c�pes. ttte pecm� st�Y bec�me hnro/d. I�
tt�t as ap� 1 am �esporo�ie fa iderWlyw�g and rt�idc�q P�'oPe+tY Mea, �n�a and metdng the ai�e a�s toc
� or Per�an Cautly Headh Oepa�tment to co�d 1tt�r e�va4mtloas. I sat�u�d that 1 am r� ��9
H�Ith � mY P� an�i �+etlanda aa d�ed b71 ths Anny CaPs oi �-
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� � PE�S�N CL�l9iV� E�l6R�N�AE�1'�'o�L HEl�L�-9 .
�L�,SE SE� �7�AC�Ei� ��6V �t3R Si�IL .�►R� .�NQ SYS��I1 L�,Y�l9'�'
Tax Map ��_ P� S� Township r" �0.� 1`�1 �1C r PfN
aaWc�r ac� '' nS s�p io� � K� i d•� � I�cres ah�,s�n� ���
���M� 1_S'1 S � 1-�r�.FF kd �, «) G5J Id �� K Ic�nc . a-E �nc� ; � Cul—Dc —.S�c
im�rovement f'ermit.
New � Addition Type of Strucfure I� c�la � ��- !'f O(�'1 G
# of Occuparrts� (11uX # of Sedmoms �
Projected Daiiy Flow: ��� g.p.
Ptoposed Wastewater System: ��I VC
Propased Repair. G � t� �� i� Sn n b t
Other
Pertnit Valid for._ Fve Y+ears ❑ Nc
Water Supply�rl t�-'� ��- t' f
System TYPe �
Qermit conai�on� .�1�5-�- II o n co�t�Cc�uF c�5 5 h c�. w� n b,r Ef�S �/Cce,� �.jrS�cm
ar�d hD me i n rc.re.�. ,5�� � n .
Owner or Legal Represe S' re: Date: . 1`� �'�� .
Authorized State Agent � Date: /�%c� J� �
The issuanca of this permit�by the Health Departmerrt in no way guarantees the issuance of other permits. The pem�ii holder is
responsible for checfting with appropriate govemirtg bodies in meeting their requirsmerrts. This site is subject to revocation if
the site ptan, Plat, or the irrtended use cl�anges. The Improvemerit Permit shail not 6e af�ected by. a change in ownership
of the sifie. This permit is subject to complianc8 with the provisions of the Laws and Rules for Sewage Treatrnerrt and
Dispcsal Systems of the North Carolirta Administrative Code.
. Authoriz�on Zo Construct Wastewatier Svstem IReauired for Buiidinn Pennitl
WastewaterSystemDescription:�•OIIUGiI�I'an�l ��%'�LiU1t�Y WasteuraterFlow: .p.d. Type:�
Faciliiy Description: �a b i lL Nt� r► z New ►� Repair CI Expansion O
Basemerrt? 0 Yes t�No � Basemerrt FDdures? 4 Yes No
Wastewater Svsbem Reauirements
Tankage: Septic Tank size�,� gal. Pump Tank size N/ rf gal. Grease Trap size '"/ �I gal.
Trenches: Totai fength �� R. Trench Width � ft. Totai Area. c�t � sq. ft.
Max. Trench Depth: � in. Aggregate Depth:�_, in: � Soii Cover. lo in: Trench Separation I ft on ceMer
Permit Expit�tion Date• � � iJ �
Authorized State Aget� -�Date: / �� ��
'Ses attached site pfan an addendum pages fo� additional permit candi�ions.
The type of sysbem permitbed a doe� � doas not differ from �te type specified on the appiication. i accept the
specifieations atthis pertnit �
Owner/t_egai Represerrtative Sigr�ature• c Dabe: ��(
O�eration Pem
System Type �n accordance with Table Va)
This sysbem Iras been inslalled in compiiartce witl� appikabla North Carol'ma Generai S�s, Laws �d Rules for Sewage TreatrneM
and Disposai, and all conditions ot 4he Improvemerrt Pem�it a�xi Co�truc3ion Authorizatioa lssuance oi this pennit implies no
guaranbee tfmtths systiem � unl! �on properiy for any 9� Pe+'� �� � .,
� �. 9-.2i- o�
Authorized Stat Agertt Date
PCHD, rev. 03/07/01
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Person County Health Department
Environmentai Health Section
Tax Map #: �`� Parcei #: 3 3�
Zoning: Township: �(ar� �Z•'�e.^
Subdivision: .�cr � Section: Lot: �f% _
Applicant:
Location-
Operation Permi�
System Type (In Accordance With Table Va): %�
THiS SYSTEM HAS BEEN INSTALLED lN COMPLlANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORiZAT10N.
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Authorized Sta e Agent Date
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Tax Map #:
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Parcel #•
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PCHD, rev. 10/12/99
PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR 1AIELL StTE LAYOUT
T���: (� �c� ��� 33S .
Zoning Tovrnship
APPlican� �Gt-fYIM�/ �'Q�f�. C�nS
�r
�,�R: �'-� e n cl ��� Cc� 1— � c-- S� L o f= l,•) r' Id Oex K
� Lp.1� L
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subdlvlsion: �K�� �S �- Cf GS g�on: �-O�
�ae of Water Suapiv:
Reauirements•
Well Permit
� Individual Commun'�ty Public
Site Approved by __
Grouting Approvetl by �-ay o► C�s
Well Log - �c -o s
Well Tag
Air Vent
Hose Bib -
Concrete Slab
Well Dritler: ` � �
Well Approved By ���J�
�at�• �I ' 28 — c� l
**See Attached Site Sketch**
Welis must be 10 feet from property fines.
Wells must be 100 feet ftom septic systems.
Wells must be �at least 25 feet from any building foundation.
Other conditions:
�'n.5-�-[ l AS �G�vwn c�r1 S i�(.c 5kc-ic�
PCHD, rev. 11/29l99
PERSON COUNTY ENVIRONMEIITAL HEALTH
WELL LOG
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Date: �-22-0� �
Owner. Sc. �-l�.r.,.�l'' � � SR# ' � � �
LpCgtlpn/T�irPrti�n�• �' �,rl'� � ,� ' �
Subdivision �Name: o�.l���: t:,IGf c��s Lot # 4�7
Drilling Contractor: � � ��
WELL CONSTRUCTION
Distance from Nearest Property Line i v Distance from Source of
Pollution ( G a
Total.Dep.th: � Ft. Yield: GPM Static Water Level a.r' Ft.
Water Bearing Zones: Depth / � t F[. � F� F� �t.
Casing: Depth: From 6 to�Fc. Diameter: Inches
TYPE: S teel � G alv anized S teel
If Steel, does owner approve: Y�s No
� � Weighc: Thickness:� '�' Height�Above Ground: I�l Inches
Drive Shoe: Yes ✓ No . �
Were Problems Encountered in Setting the Casing? Yes No � �
If "yes" give r�ason:
Grout: Type: Neat Sand/Cement / Coricrete
Annular Space Width � Inches . � .
Water in ATmular Space: Yes No
_ .. Method: Pumped � - Pr�ssure � Poured � - � � - �
Depth: Fr�m O to � O 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 .� No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND TH AT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C^vLi�i'I'Y HEALTH DEPART .
. C� �-�z=�i
Sig turc of C n actor Datc