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Tax Maa #_,,,, - �l a
Paresl #: �. � t#�-/ 9
Perso� CouMi► Hesitlt Deaartrnqnt
Enviro�me�i Healtl� Sectlon
�- �_ � -• - � �;t� �x
IF THE INFORMA?lON IN THE APPLlCATION FOR•AN IMPROVEIYIENT PERMIT IS FAL91Fl�. CHANGED OR THE SRE IS
ALTERED. THEi�i'THE 1MPROVEiUIENT PERMR ANO AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALlO
i� �����MfQOCfZg011tipfOs�V9 dMA10fj: � G rn m u fii n �..� �i d n S
i'{Ofi10 i�t10flQ. � 6�I -� S(o �. • l� � S �� S�� �i.t r ri 1{ �; 115 l�Gi�
BLL3�10� �1017e: ! 1 1Qc��,c�n�r�
Z� Name artd address of cucnent oMmer: �a �-.� r
3) Property �iption: Lotsm� I•04 T� � r
D�edio�ts to the propedy p�g road rtames and nun�sk I.�� ; Ic1 D4 k l.a„ t
r�-�� ���.��' R,1,
�
� Proposed use and s�vctura oescriptlon: ana�eti ra each atthe fo0awing que�ocu:
ai PraPosed �6dstlnq Q
b) Stfdc Bu�t q Modular �. Si�le Wfde 0.� Wida CY
� Number of Bedroorr�x �_ � Nuct�6er af occ�ant�� oc peopie to
e) Baaema�rt Yes Q No 47�iFyea. � ai basemeM ti�dtuex
• t� Garbaga Diaposa� Yes 4 Nc 0' �
9l 4�ot Proposed Strucbura: VVid@�: � Dapl� �
be sanra� �
���phr �: �e q�naww a o� � a�, �ca, c�ay a. sw�w a.
Are acry weMa on a�oining propat�t Yes 0 No �'ltj�es, lodion
6j P� indicad D�aii+ad Syat�am 1YPe: (syatecna can be r�d ln qr�r of Y� P�l
�Conventlonal Mocii�fled C�an�ionai _ Ai�w �„�nnovattva .
Ottw (sp�dij�:
�, _ .
t�EARLY 3TAKE ALL CGRNERS AND L1NES OF THE PltOP9tTY.
3TAKE THE CGRNEiiS OF ALL PROPOSED STRUCTUFSES.
PLEASE ATTACti SURVEY PU1T OR SRE PUW TO TH{S APPl1CAT[ON
��Y �� bo the Pe�on Caunty Health 0� ior a a�e nv�on to� tfia a�-siie sewa�pa � sY�n
tt'�s above�osaibad propecty. l� Htat the co�tenb oi this appBr�tion ace ht�a and ra�c�t the cnmdcnt�n iaa�Les bo
Ptacad on the pcvpecty. ! undastand � ths s�e ts aiterod cr the &�ierded u:s � the pem� shaY bec�ne inwNd. i undesst�
tltat as ap�BCartt, I am rospo�ie tar Mec�tying and rt�rian9 P��11 �, �� and nreici�g ths a�e a�is �
Perso�nd af the Person Ccturty Hesqh Dapartmetrt to canduci their avakm�s. I ia�acatand tt� 1 am t� ��9
Hea�h D !f my �H c� any wa�tands aa daip�ed bY ��m1f ���s-
9-�-�� o0
OC RO�f63�i1�(VB Qg�p
PERSON COUNTY ENVIRONMENTAL HEALTH
�
Tax Map #: "( D Parcel # ?� Township
ApPiicant 7� in I'N �l ��/21C Su6dWi
Locatlon:
improvement Permit
New � Addition Type of Structure '� `�� ,',��
�/
# of OccupaMsa_�� # of Bedrooms � Other
Projected Daily Flow: �_ g.p.d. Pe it Va{id
Proposed Wastewater System: '
Proposed Repair.��,l�e„� ' �-e-
Permit
PIN
PhaselSecUon Lot# / �
Water Supply J''i'i Vrv� ��//�
Years O No Expiration
System Type�
Owner or �egal Representative Signatur • Date:
Authorized State Agent: ' • Date: �-�� "' ��
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit holder is
responsible for checking with appropriate goveming bodies in meeting their requirements. This site is subject to revocation if
the site pfan, plat, or the iirtended use changes. The Improvemerrt Permit shall not be affected by a change in ownership
of the site. This permit is subject to compliance with the provisions of the Laws and Rules for Sewage Tr+eatme�rt and
Disposal Systems of the North Carolina Administrative Code.
Wastewa#er System Description: �
Facility Description: 3�� -�'%z
Basement? O Yes o �
Wastewater Svstem Requirements
4 Yes
Wastewater Ftow: J��� Q,p.d. Type;��.
New � Repair O Expansion ❑
Tankage: Septic Tank size ��D gal. Pump Tank size `— gal. Grease Trap size — gal.
Trenches: Total length � ft. Trench Width 3 ft. Total Area /o�c� sq. ft.
Max. Trench Depth: �� in. Aggregate Depth:�_ in. Soil Cover. �� in. Trench Separation �ft. on center
Perrnit Expiration Date: �U, ^�a2 " ��_
Authorized State Agent: , ��. Date: � � � � ��
��
'Ses attached site plan and addendum pages for additional permit conditions.
The type of system permitEed ❑ does �does not differ from the type spec�ed on the application. t accept the
specifications of this permik
Owner/Legal Represerrtative Signature: Date:
Oaeration Permit
System Type (in accordance with Table Va)�
This system has been installed in compliance ' applicable North Carolina General Statubes, Laws and Rules for 3ewage Treatrne�rt
and Disposal, and all conditions of fhe Improvemerrt Permit and Construction Authorization. Issuance of this permit implies no
guaraobee tfiat the system installed will function properly for any given period of time.
�n"��-- C'0� � -��-� o I
Authorized State Agent Date
PCHD, rev. 03/07/01
_........-----,._._.. �__..._-------._._.._..... . _.. _.. .
Person County Health. Department
� Environmental Health Secfivn T�c AAap #:
� Parcel #: �_ � �
� S1TE S�ETCH _ _ -
. . _ . .-_ ... ._. � ,1 � /�(y
��I
� /7J{�j% - 1 r�
pplicant's Name � $u ivision/Sec�tioNLot#
• , � �Dl �4� .
. Authorized tate Agent Date , �
System cor�pnne�r nprestnt appraxi�iwte coruours only. The co�dr�ctor �flag �tlie syshm
� prior to beg�iu�ig �lie installation to tnsure that proper grade fs ma�tained
/l/dTc � ,�-/?5��/ ��'c'/u��,ts ah C'dYt 7bc�r;
l�G� �i �S,S �zt !�✓r/�� GC �G/ltS'� jL�/"ioY'
y�
� ��s� 1��� .
' ��,�e saG
' w,���Du� �,�.
scale: _ 1 � � S"D `
�
�
�
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, ��F' \
��n�
Person County Health Department
/� Environmental Health Section
Tax Map #: !'1�i l� Parcel #: � 3%
Zoning: Township: �� �-'�" � + ��
Subdivision: ` C-(� Section:
Applicant: ki`�
Location•
Lot: �
Operation Perm it
System Type (In Accordance With Table Va): � I
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZATION.
�b��-U�
Authorized State Ag t Date
� -� -c�
�--i � 2
j ^� ���Y
�,i� I� ��� ��
.
Tax Map #: � �D Parcel #: � � %
5'1
PCHD, rev. 10/12/99
Person County Health Department
Environmental Health Section
Zoning: Township: F� � � � � V'e.(�
Subdivision: � ; � e�C ('C'.S Section: Lot: �_
Applicant: U �-1,�7�.i i�S
Location: M�9��
Operation Permit
1. LOCATION AND SEPARATION DISTANCES
A) System meets .1950 setback requirements ✓
B) Distance from system to any welis � a-� '�-
C) Distance from septic tank to foundation lQ'
D) Distance from system to property lines � b' �-
2. SEPTIC TANK
A) Visually inspect the exterior walls and top of the tank 1/
B) Visually inspect the interior wa11s, baffle, tee, filter, riser, lids, air vent,
bottom, and water tight outlet '�
C) Date of tank manufactureS -�i-a�YSI
D) Tank serial number �-�-5—/o7JtZt5T$-/4Z
E) Liquid capacity of tank 1 6�2_— gallons
3. SUPPLY LINE TO TRENCHES
A) Grade �(1/8 inch per foot minimum)
B) Material supply line is constructed from SCIf yO�C
C) Diameter U "
D) Length �„ ' �
E) Distance from tank to drainfield/distribution device "�_
4. DISTRtBUTION DEVIC�E�(S) . ��
A) Type {�.�-�C�.�c
B) Is Device water tight
C) Distance from the distribution device(s) to the trenches
D) Is the device on a level foundation
E) Does the device perform according to its design specifications
F) Record the inlet and outlet elevations
5. NITRIFICATION FIELD
A) Trench depth � y inches
B) Trench width � inches �,�"�
C) Distance between trenches T
D) Number of trenches 3.
E) Length(s) of trenches I 30 . 1,30� Q,� �� c"�
F) Aggregate depth 1 ainc�s
G) Aggregate material and size `7
H) Record septic tank outlet elevation '
I) Trench grade SLt Gi�LCL..,jL.�� (< 1/4" per 10')
J) Step downs
a. Minimum of 2' of undisturbed earth �
b. Proper rise over step down 'V'
c. Solid pipe used �H�-(.o P✓��-
d. Elevations of step downs �(Record elevations and show on as built)
See "as built" plan on attached sheet.
PCHD, rev. 10/12/99
PE�S�(V CC3UNiY E�ly'IR�NIVIE�IT�►L HE�►LTH .
PL��►S� �E� 0��'�CB�E� PL�4�9 F�R VUE�L S1TE L,�''�L�llT
�� � d P�# 3�'7
�
ZoNng
Applic�
I.ocatla
i
Subdtviston:
Township
Sectlon: LO� �
Well Permit
i
Tvae of Water�Suppiv: �Individuat Community Public
Reauirements:
Site Approved
Grouting App
Well Log �
Well Tag f
Air Vent
Hose Bib
Concrete Slab
Well Drilier;
i
�
.. ["�'i�_-�• �
Well Approved By:
Date: �� � � — /� %
�
**See Attached Site Sketch**
Welis 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:
,►� �vv� 6� ��er ��,�1� � � ��`�, �- [ 2--��
�� � �
PCHD, rev. 11/29/99
�
PERSON COUNTY ENVIRONMENTAL HEALTH
l;�1�1L1�yZ�
Date: � -/.��-D� '
Owner.
Location/Directions:
SR#
Subdivision �Name: �.��.'� cr� Lot # �/q
Drilling Contractor: � � ��
WELL CONSTRUCTION
Distance from Nearest Properry Line J v Distance from Source of
Pollution ( G a
Total.Dep.th: FG Yield: ,� GPM Static Water Level a2S—' Ft.
Water Bearing Zones: Depth /0 t. � Ft F� �t.
Casing: Depth: From 6 to�_Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel
If Steel, does owner approve: Y�s No
� � Weigh� � Thickness:�, '�l Height� At�ove Ground: /�/ Inches
Drive Shoe: Yes ✓ No . ..
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" give reason:
G.rout: Type: Neat Sand/Cement / Coricrete
Aiulular Space Width � Inches �
Water in Aimular Space: Yes No
_ .. Me[hod: Pumped � - Pr�ssure - Pour� � - -
Depth: From O to �2 4 Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag lbs.
If mixtuie (sand, gravel; cuttings) - Ratio: to
ID Piates: Yes � No � �
� 4 x 4 slab Yes � No
I HEREBY CERTIFY THAT THE ABOVE INFORM�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON C�`vi�TY HEALTH DEPARTME
��i -�� �o�
Signa re of Contractor Dat�