A40 336�'
' 9 �� 7-�0
p�oon�on o�: �-
Amount Pai=LZ 1� l J'G .��
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d ,a� �o (
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Perso� cou�tv Hes oeaarbnertt
Errviroemerrtil Heaitt� 3ection
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Tax Mao #: .Q-- �t Q
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IF THE INFORMATION IN THE APPUCATiON FOR•AN IMPROVEiI�ENT PERMIT IS FAL31R� CHANGED OR THE SfTFif�
Ai.TERED TFIEN THE IMPROVEiUIENT PERMIT AND AUTHORiZAT10N TO CONS'TRUCT SHALL BECOME INVAUD
�i �� "J• I�YRONigo�p(Osp6c.�tiY9 OWnOij: �a mm �n ���k>n S
Homs Phon� .� � �t - � 5 /� � • A�dd�eax . C �-a . S ' �l 1, r � t r ►7, � � ! s� Rc1,
Btlsi�s PtWne• �� • )�-�� h n r r�
Zj Name and addr�as cf csurent owner: �,, ,:r -�
3) Property Descrlptiom lotstz� �• b�, Ta� _�_
D'aedtons ta the propetty p�g rnad, nam�;s,�nd tuunbeis� ���` I �,� ta� k l� �, N r
4) Ptvposad Uss and Struct�trs Descripti�o�: anawet eactt of the fo0awin9 qc�fona:
a1 �Po� �9 0
b) SHdc Bu� q Noduiar �. S1ngb Wtde 0. Oouble Wide 6�
� Numbet af Bedtoorns: ` c� Nutnber of ocxx�pants� ot peapia to be se�ved: �-
e) Baasma� Yea Q No [,Ylfj�es. � of baaemert fixtucax
•� Garbe9e aisPosa� Yes 4 No [�Y
� 4�aas ai Proposed Strcx�u�a: VVidth: � g Dap� �D_
i��PPht �: Privaia q(new Q or aodstin9 �. P+�6c 4 Co�Y 4 Spdn� �.
Are any weqa on a�oining properi�l Yes 0 No l3'ifi yes, locatton
� Pl�asf Indicab Daii�sd Syat�am 1jiPe: (syatema can be raNasa! In oc+d� af Y� P�l
VCoavetttlo��al Yo� Conv�ntlonal _ Al�attyr �ovatlyi
Oth� (sp�:
CLEARLY. 9TAKE ALL CORNERS ANO 11NES OF THE PROP�RTY.
3TAKE THE CCRNERS OF ALL Pi�OP08ED STRUCTUii�S.
PL.EIISE ATfAC�i SURVEY PLAT OR SRE PLAN TO THIS AF�ICATION
I herobY meke a�6�n to tl�e Pe�on Camty Health 0� 4or a m'be ovalua�on %r the a�ibe sawaqo disPoaai syat�
tha above�lesaibed pcope�ty. l agoea tltat 1ha �ts of tl�h appYcatlon are tn� and t� the mmdrtu�cn � to
p�eCad on the pc�oQecty. ! w�and �tho s�s b altered arthe ir�ndeci uss c�anpes.lhe pennit shaY bs�oocne inwiird. i undesst�
tltat as ap�artt. I am nespona�le fa Ida�ing and rt�ic�9 WoPehY ii�a, co�ner� and maldng the sim ac�le ia�
personnd of the Person Co�utty Hea�h �trnesrt bo condud tl�ir avak�loc�s. l ta�nd tt�at l am reapa�ie ��9
He�th ff my ptop°�Y�;.�r� � � � � bY � � � � �.
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PERSON COUNTY ENVIR�NMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAYOUT
Tax Map #: A�� Parcel # 3 3�o Township ���+ "7 ����'r PIN
/, �� �,�
Applicar►t ���� s>, y Ct k.i/G,rI�S Subdivision rr -- ,C s� ' /RS _ PhaselSecSon Lot#
`� n� � _ n i i _ .
Locatlon:
Gu
imurovement Permit
New ./ Addition Type of Strudure �,6/� S'.�.�� f7i�f, %y ✓��S'��=e�lUater Supply /i"�'vt�'�e Gc%��
# of Occupants� 6 # of Bedrooms �_ Other � System Type
Projected Daily Flow:?� �c_ g.p.d. Pe it Valid For. ive Years ❑ No Expiration
Proposed Wastewater tem: ' �
Proposed Repair. r <r-
Permit Conditions: ���v S," /e S�c �,/
Owner o� Legat Represerrtative Signature 1-�= Date:
Authorized State Agent: � �� /� Date' �f %?% � � f
The issuance of this permit by the Health Department in no way guarantees the issuance of other pertnits. The pertnit holder is
responsible for checking with appropriate goveming bodies in meeting their requirements. This site is subject to revocation if
the site ptan, plat, or the irrtended use changes. The Improvemerrt Permit shall not be af%cted by a change in ownership
of the site. This permit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatmerrt and
Disposal Systems of the North Carolina Administrative Code.
Authorization To Construet Wastewater Svstem IReQuired for Buildinq Permit)
Wastewater System Description: C.�n v�?�z�`� �Oncz-/ Wastewater Flow: 3� d g.p.d. Type: _�
Faality Description: 3.6/Z S.i:v� ��?r,'� � si' New �� Repair ❑ F�cpansion ❑
Basement? O Yes o Basemen ixtures? ❑ Yes �fQo
Wastewater Svstem Repuirements
Tankage: Septic Tank size �� d gal. Pump Tank size gal. Grease Trap size gal.
Trenches: Total length ��a ft. i'rench Width _�_ft. Total Area ��r� sq. ft.
Max. Trench Depth: ��t' in. Aggregate Depth:� in. Soil Cover. / a in. Trench Separation �ft. on center
Permit Expiration Date: � �/ — O�E
Authorized State Agent: /s`4� L"� ,�J • Date: Fl iZ /^ a�
*See attached site plan and addendum pages for additional permit conditions.
The type of system permitted a does �oes not differ from the type spec�ed on the application. 1 accept the
specifications of this permit
Owner/Legal Representative Signature � Date; w� ^ v'
Operation Pe it
System Type (in accordance with Table Va)
This system has been installed in compliance with applicable North Carol"u�a General Statutes, Laws and Rules for Sewage Treatrneirt
and Dispasal, and all conditions of the Improvemerrt Permit and Canstruction Authorization. Issuance of this permit implies no
guararttee that the sysbem installed wi(I function pnoperly for any given penod of time.
Authorized State Agent Date
PCHq rev. 03/07/01
• P�r�ora +��unty 13ealth. Depariment
� �s�vi�nmental D�ealth Sectlorn �� {�s� �: �-��° .
� � Par�ai �: 33�—
� Si'�'lE S�4E'�'C� -- _ . . ..
,,,�� , �, < l�►iF r
� AppUcani's Name
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. Autttorized Agerit
G �4,' .� .��S��f�
Subd sioNSectton/Loi#
J��f,�r�f
Date
Sy�a�t campone� npraserrt appraur�inate cmttours orrly. Ths controctor muatJiag the systpie
prior to begin� tbs in�lallat�on to i�s�ire that proPer 1�rade �S marbrtained
Sys��
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� :' System Type (In A�c�ardanc� Wiih Tabie.Va); �
Ti�IS SYSTE� 4�15 �E�1 IAtST�►LLED tN G�MP!_lAiYC� Wii'1� A►PPLiCABL� NOI�T�D�
C�iOLlN�►► G�i�lE3�AL STA'il�'6'ES, RULF.� FaR S�1IIAGE TRE�►TAIEiHT AAID DISPOSAL,
.A�ID 'ALL CDNDC�ONS OF '�E IMPR�JVE�IIEi11T �Cf' �AiVD Ct3NS'T��]CTION
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PC�iD, r�er. 10112/99 .
PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: _� ( � Parcel # � � �
Zoning
ApplicanL e- "' •�t�, f7`Gi ,<G/h S
i _ n
LocaUon:
Township ��Cc-'� �i�i�✓�
/1��/ a <
Subdivision: �"`''-�� Section: Lot�_
Well �ermit
TYpe of Water Suppiy: Individual Community Public
Requirements:
Site Approved by
Grouting Appr v d by
Well Log �
Well Tag
Air Vent
Hose Bib
Concrete Slab
Well Driller:
� v
Weil Approved By: � , Date: ���C� ^
**See Attached Site Sketch**
Welis must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Welis must be at least 25 feet from any building foundation.
Other conditions:
r�
PCHD, rev. 11/29/99
�
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date: _ �- v-di '
Owner. � ,��.�.��`�s � SR# ' � � �
���� � � . .
Location/Directions: �
Subdivision �Name: fl�l� � . ��r � Lot #
Drilling Contractor: � � ��
WELL CONSTRUCTION
Distance from Nearest Properry Line ! v Distance from Source of
Pollution ( G a
Total.Dep.th: /�'D Ft. Yield: 4 GPM Static Water Level QZ.S—' Ft.
Water Bearing Zones: Depth /0 4[. Ft Ft� Ft.
Casing: Depth: From 6 to /�c� 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 . �
i
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 Armular Space: Yes No
_ .. Me.thod: Pumped � � - Pr�ssure � Foured � - � �
Depth: Fr�m O �o �. � Ft.
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 REGULATIONS SET
FORTH BY�THE PERSON C�ui�TY HEALTH DEPARTM �
� - "- . --
-� o
�: �' �{:o �
Signature of Cont actor Datc