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A40 338s �1- a y o�Q PQo+tcaaon oate,; Amount P�id: � � G, o O � 0 �� 30 3-6 � � �esl #: �o t � s� Persoe Courrtv Hesith Deaarbner�t Environmenhi Heaith Sectton �.i , �� i�. .�:�� 1F THE INFORMATION iN THE APPL1CATiON FOR •AN IMPftOVEiI�ENT PERMIT IS FAL91Fi�. CHANGED OR THE SiTE IS At.TER�. THEN'THE 1MPROVEiUIE�iT RERMIT AND AUTHORtZATION TO CDNSTRUCT SHALL BECOME INVALID i� Pu!�l�il_� pf��l�� "I• ��Mf[lAdi}�fl�pYC$i Yi CWfl�O��y:� �Q rn �m U� �� U.�J1 �C ��C !7W{IY r1R�11R � lnt"� `�.--( �� o� ' r11YWQi�.� ��`1- (�I i� I`f� �� I�L 1� �� Btninea,s Phot�e' � ► ' �4��,h�r o 2y Name and addcess of curreat ownee � d rr. t 3) Propacty Oesctiptlon: l.otsfxx �, no Ta� �._ D�i011a ti0 t11B p[Ope�y (I�g �id t18[T1�8�1d R�b@c.t� (� �� I r1 7� s� k 2- ct n �. 4j Proposad Uaa and Structtttp Descriptian: a�tawec ea� af ihe fioaowin� 4ues�cu: a� ProPwed 4�"E�ds� I] b) Stl�Cdc Bu�t q bbdulac �. Slrqie VY(de 4 Double Wide � � Numbet ot 8edtoomx �_ c� Ntunber of o�nts� oc peopls to be sen�ed: � e) 8aseme�rt Yea Q No l'9-lf'yes. # of basanent fixhtcex • f� Garbage OiapOsa� Yes Q No [!� • � Qh�sionsaf Proposed StruQ�u+�: VVid@t: 28 pepltt � �1 ��PPtY �: Ptivaie a(naw a ac aodaW9 al� Pt�c 4 Co�mnu�Y o. Spting 0. Aro any wena an adjoining popaty/t Yes 0 No �lt�ysa. focatton 6j PMass Indicata D�sii�sd Syai�m ljlPs: (syaiema can be rrNo�d tn c�dir of Y� P�i � entlonai Yo�fled Convsatlonai _Ai�c�atiw �Jnnovativa CLEARLY. STAKE ALL CARNER3 AND L1NES OF THE PROPERTY. 3TAKE THE CORNERS OF ALL PROP08ED STRUC7URES. PIEASE ATTACN SURVEY PU1T OR 5RE PtAN TO THI3 AP4UCATiON ��Y �� to the Pecson Ca�mty Heaith Oepart�t ibr a a#s avaWafton tor ths a�ai�e sswaqe disPos�l sy�m tha above�iesaibed propetiy. l aproe tltat the �b af thb appic�on ate true and ropt+�ac�t the ma�airtu�n fac�laa ta Pteced on 1he propecty. 1�r�d if the sim b alGered orths ��ierded uss c�nqes. ttte pecm� st�Y bacame inva�d. l tx�dets� tl�at as ap�t, I am rosporn�de, toc identi�ing and �ri3n9 P�l ii�, �meca and inakirr8 ttte si6e a�is �a' personnd of the Persan Co�urty HesHh De�rtrnatt to cot�dud the3r avaksatlens. l ta�derstand it�t 1 atn t� ��9 H�th !f rtry propertY�N� any M�eUanda aa desi�bed bY ihe Arm11 ��rs- � _��', o a or t�al Repcesenta#[ve . oaLe Tax Map #: /T_r7 lJ Parcel �t Appitcan� s rl,, . Locatlon: �/� PERSON COUNTY ENVIRONMENTAL HEALTH Township /�/G' K. ✓fY PIN 3ubdivision �' _ Phase(Sectlon lottF �� %/ " Improvement Permit New �Addition Type of Structure �1�/Z Siiw. �P/'a`», ltv f<RS. Water Supply � o� / # of OccupaMs �-8� # of Bedrooms � Other '—" Projected Daily Flow: _�� 9•P•d Pe it Valid For. ive Years ❑ No Expiration Proposed Wastewater tem: Pw ' Proposed Repair. � ' Permit Owner or Legal Representative Authorized State Agent: S System Type� Date: � ^ � '� � � Date: _ � '`—D% The issuance of this permit by the Health Department in no way guarantees the issuance of other pertnits. The permit holder is responsible for checking with appropriate goveming bodies in mee6ng their requirements. This site is subject to revocation if the site plan, plat, or the intended use changes. The Improvemetrt 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 Treatment and Disposal Systems of the North Carolina Administrative Cade. Wastewater System Description: Wastewater Flow: T�V g.p.d. Type: � Facility Description: �.�i� . 5.��e �l ss,, lh �S�ota<-�.c� New Cb� Repair ❑ Expansion ❑ Basement? ❑ Yes L91�o asement Fixt es? 4 Yes [�i�f� - Wastewater Svstem Requirements � Tankage: Septic Tank size B �� gal. Pump Tank size � gal. Grease Trap size �� gal. Trenches: Total length �3� ft. Trench Width �_ft. Total Area %Oo sq. ft. Max. Trench Depth: �,� in. Aggregate Depth:�_ in. Soil Cover. �_ in. Trench Separation �! ft. on center Permit Expiration Date: � � � � 6 Authorized State Agent: S Date: �r f r�l *See attached site plan and addendum pages for additional permit conditions. � The type of system pertnitted a does �� s ot differ from the type specfied on the application. 1 accept the specifications of this permit Owner/Legal Representative Signature: Date: G-� �6j � O erati Permit System Type (in accordance with Table Va) �— � This system has been installed in compliance wAh applicable North Carolina General Statutes, laws and Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction Autlwrization. Issuance of this perrnit implies no guararrtee that�sysbem i stalled will function properly for any given pe ' of time. � Authorized Stat Agent Date PCHD, rev. 03/07/01 ........ ._..___�_..._... �.._.__._._..._._..._. _.._..... . _.. ... . . Person County Health. Department � Environmental Health Section T�c Map #: � � � Parcel #: ,��— S1TE S14ETCH . _ - ._ . ___. , .S'ls��l��i � ,rl�irs � ; � Ps , .SD plicant's Name Su (vision/SectioNLot# � � �sS'. ' �/r�l - . . °— " Date � � . Authorized State Agent , . � ; Sy�tem co�npa� represent appraurimate cnntours only. The contractor mus�tJPag the syst�m � prior to be � fhe inslalWtion io insure that proper grade is mabetained SCaI@: �1' �O � �� %r�; C�n�'��..s _i, �",-� S��l/.d� fnS��/� n ��,r; r�� o�� s�s� � �� , / � �r�� c �ra�.s'� f t'l',dr' � Person County Health Depariment L%�`� Environmental Health Section Tax Map #: 1� v Parcel #: � Zoning: Subdivi: Applicar Locatior Tawnship: � ( r 1� �ction• Lot: SV .� h y / � f��/�d-�rso�l Operation Permi� T e In Accordance With Tabfe Va : �� System yp ( ) THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH CAROLlNA GENERAL STATUTES, RULES �OR SEWAGE TREATMENT AND DI$POSAL, AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION AUTHORIZATION. S � aa o � . Authorized State Agent Date QL �� P7S lo oe� �� / y a S_g_amol 1 , I . �? a krom � L�_ �n8� w� �� 30 � � �3: 133� rJ . � Ly; 13n� � L s = 3� To =� syo , .�5'`� __ - r� rr r � 5=�, H , „ So Tax Map #: Parcel #: P�L PCHD, rev. 10/12/99 PERSON COUiVTY EiVVIR�NMENTAL HEALTH . PLEAS� SE� A�'�'ACHED PLAN FOR WELL SITE LAYOUT Tax MaP S: .�� Parcel # �� ZoNng Townahip r lW1 ��VV�r ApPlican� Locatlon• � • ► `v ��n v'-� � - 1 Qa� R� �e� �o Subdivision• sectlom �� Tvae of Water Suppiv: ReQuirements• We8 Permit �dividual Community Pubiic Site Approved by � ��13 �� Grouting Ap roved by Weil Log ' � Weli Tag Air Vent Hose Bib-� Concrete Slab _ Well Dritler• VUell Approved By: � • �, �D - a�� -- ,�c,�� ,��i�.�. . y� �� - �-S Date: 6 **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 fo� ��''�ti� . Other conditions: PCHD, rev. 11/29/99 Date: - 3 -�/ ' Owner. ,t27�r,:�� Location/Directions: PERSON COUNTY ENVIRONMENTAL HEALTH �r WELL LOG SR# Subdivision N�me: _ ac.ICt�'c,� Lot # SQ Drilling Contractor: � � �� WELL CONSTRUCTION Distance from Nearest Property Line 1 v Distance from Source of Pollution ( G o Total.Dep.th: �/ Ft. Yield: /� GPM Static Water Level aS' Ft. Water Bearing Zones: Depth :�S�LFt. �� F� Ft. � 3~�� Diameter: c e Casing: Dcpth: Fr�m � t��C _ In h s TYPE: Steel - Galvanized Ste�l If Steel, does owner approve: Y�s No � � WeighG � Thickness: l� 8'�l Height�Above Ground: /�/ Inches Drive Shoe: Yes ✓ No . Were Problems Encountered 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 � - Pressure � Poureci � - � � Depth: Fr�m O to �, � Ft. Materials Used: No. Bags Portland Cement Weight of .1 bag__lbs. If mixtuie (sand, gravel; cuttings) - Ratio: to ID Plates: Yes � No � � � � � 4 x 4 slab Yes � No I HEREBY CERTIFY THAT THE ABOVE INFORMr�TTON IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH R GULATIONS SET FORTH BY�THE PERSON C�uidTY HEALTH DEPARTMF�NI'� SiQna�furc of Contr'�ctor _�3 _�� Da« ..� N a