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A40 346
� .,� . s q a 7� o AQopcatlon Dat.: � �+�+���1 �6: o0 a ��3a3 6 o� -0 � ' • l� ! � � '.: L'l! -11 � r �i� � � L� • �.� i . � t� �►,� �i� , i.i_ _ r . IF THE INFORMATION IN THE APPUCATION FOR�AN IMPROVE�ENT PERMIT IS FAL91Fi�. C�WNGED OR THE SlT� fS ALTEit�D. TiiEN'THE IMPROVEiV1Eid'T' PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID �� P�m� req�+s�ed bl •�Ovm�itig�il�pr�v� OwnOi�: .� m rn ,� r�tl r.i k; h�, Ho111s PhOri� 'Z�6,�!- � S� 2 � Aid� S � ,.�,.-i 1, vn� rls F�':,f� Bl1�fO�S �I0f1a: � � � r�..-i i � r � 2� Na�:u a1u1 addr0is of curne�t OW�N% . lY. m�C 3i �P��'tY �P�ot� Lat aix� 1 do Ta� _ F r3 Diracita�s ta the propecty (1t�q tn�d ascnes and ruuN 4) Frcpos�d lJs� and Struct�tre Gscriptiaa: anawet esch af ths fodowLtiq que�ona: � ��� � � b) Stldc 8uit 4 Moduiar q Slnale Wide Q Oaibie Wids � � Number a( 8edtooms: ��-L � Number of oax�Qants� or peopie to be se�vec� � a) Basement Yea q No l�E yea, � of basemec�t ttx�usx '� Gacba6a D�a� Yes 0. No � � Qh�aionsof Ptopoaed Strucltue: VVidtfi: � Dapltt f'o � � �hr � �va�s q (oew o a� aoa�ne �, � 4 �r a. s�w o . Ars any wdls on adjoiNng poopat�t Yes 0 No E3�Ifyes, location 6j PNas� Indicab D�aii�d Syamm Tj�s: (systxna can be raR�io�d 1n a� at Y� P�? �_Cattvsctttonal IAodifted Comsntlasal _ A� �,�nnovatlw OttNr (sp�ityj: CLEARLY. 3TAKE ALL CORNERS AND UNES OF THE PROP9ZTY. STAKE THE CORNERS OF JLLL PROPOSED STRUCTURES. PLEASE ATTACtI SURVEY PU1T OR SITE PUW TO THl3 APPl.lCATION ��Y �� ta the Pe�an Cowrty Health Departrt�ar�t Lor a a�s evaktatlon 1br the a�-siie sa�wape dbPos�l sysi�cn tha abore�described propedy. l ag[ee that the c�r�,enta ot this applk�tion acs tcus and r�u the tna�ortuun �iea t�o Placad on the pcaQecty. ! undorstar�d if the siCe b ait�ered atha ir�Eended ua c�anpea the penttit shaY bewns invatkl. I t� tt�t as app�cant, 1 am respons�e far tda�ying and maridn9 P�'oQertY iinea. co�necs and rt�alcing tite aibe a�e fiar pataonnal af Person Ccunty Hesqtt Departmettt tn ccndu�ci thair avdtsetlons. l ta�atand that 1 am t�ap� ���4 Hea�h D tf my � any watlanda as dai�0ed b7f ��mlf �Ps ��rs- _� ��(�oa OC L.6Q8I RO�f�O�ItBt[VO . Og�j P�#�SL�N CL�UNTY E�lV1ROPIME�YTAL MEALTH � Q��SE S�� A�Tr�Ca-iEi3 i3!_.4AI F�R St31L ARE.�►, AND Si(S�'EaIA LAYOl93 rax etap �k �%� 7 � pued f � I 3� ko Zoning Townsdip_T�(� I •�/ t/e r . � / / _ �. •- AQpltGanC Locatlo ��: a���� �, �� �� � tmproveme�t Permit � , A 6uildinq s�ermit cannat be issued with oniv an Imarovement Pertnit New � Regaic Adddion Type of Struchue ��� Water Supply �t �� # of occupants #•of Bedrooms T Other 8asemeni? � Basemerrt Fix�res� Projeded Daily Fiow: �Og.{�.d. Pem�it VaUd For,�f F'nre Years 0 No Expira�on Proposed Wastewater System Type: C��rl'v2n f�avia � Pump Required?' Yes X� No � Proposed Repair : ' o rt v�e�b r�a I / /� ,1 Permit Condliions: t�P1 S ysf�r� S` m��,`ra��7�c -f�.utiera-�io., AH�. l0� The issuance of this permit by the Heanh Oepattmeatt in no way guararttees the issuanca of attter p�rmits. The permit holder is respansible for dtedcing with appropriate goveming bodies In meeiing their requirements. This site is aubJect to revocatton if the sibe plan, plat, or the irrtended use changes. The Improvament Permit siiall not be affected hy a cfiange in ownership of the sits. This pemtit is subject to eompl'�ance with the provisions of the Laws and Rules for Sewage Tr+eatrnent and Disposal Systems of the North Caroiina Administrativa Code. Type cf Wastewater System Fac�ity Type: �Jr, �F D - easement? Q es - o Wasbewaier Syatem Reauirements . Sept� Tartk Size• e 0 D g�p� Wasiewater Flcw: � .�.d New� Repair �Expansion ❑ Basement Fnc�uas? L1 Yes�No Pump Tank Size: gaUons Total Trenc#t Length: S- � feet Maximum Trench De� � ine�es Aggregats Depth: ��in. Maximum Sai Cover: (D ind�es Trench Separation: � Feei on Center Other: � Pertnit Expiratian Date- �� � Authorized State Age� ��; ��- i Od . The type oi system permitted Q does ❑ does ot. difter trom type specified on the appi[catian. ( acr.$pt the speciflcattons of this permit , OwnedLegal Representative Sig�tature: / D�. ,� - l�-O,� . PC}-lD, rev.11/18/99 u l . ..__��.. _.. _ .__..._......._...___..._ .. --- ��rs�n Caunty �iealth. aepartmen! � E�e�ronme�fiai Hesith Section Tax��Aap#: � ��� _ . . � � Psresi �: � ►�F �� � Sii'E S14�i'C� � _ . _. � ' � �wl����ge A��s (�+ s�' - -..-- ��, . _._ - �,w ��.s AppU s Name SvbdivisioNSedioNLot# � • /2- / �d . qutltorized S Agerit �e . . ,S�►ata�t ca�� �r.ese�rt appraurim�e cn�rtaraa on!}. Tbs ca�r mrrst, flag tJ%�t - p�or m� tlie in�allation to imurt tliat AroPer grade is �ralntaiued '. �76.G1' . / 1' ' 1 L 6oi ��i Scaie: �'' =ltp � -- 6�� T �S .� ,�' A G� S I � �- 1 � � � o �o � y�w � , � . . �`' �S ` ,. ho Zb �8' L�' l�( �i� �� � _ _ _ _ �c,' �, (�(tiOtr��.lrq0.�e.. Fo" V � � -st. � J ���� �� ���� �� V�' L r ,� �� ������ I��.�a-�� � �m�.71 ���.7I-�. ��x N1-�,p � ��;r� �I � ��u:bdiivi:s�i�an � _ � h•a:��S��tiai,l:° at f � : . �r��i � � �r � -�t � � � System Type (in �+ccardat�ce Wifih'Tabie Va): . THIS S`lS��ii 1-I�S� f3E�i� IRlST�LED !N C�i1�P�.lANCE• IAPITH s4PPL1C�►�LE N�R'f8� CAROLl1Vie► C��iNE€�►LL STA►�'UT�S, �RLlL�S F�� ��E'�VAGE ""F�E.�TiYaENT �!D �9SPOS�►i., . � � �!D �.1.. C�NDiTIONS �.06� THE I�APR�lIE�Er�T PE�6T �9D. �C�NS'��dUC'T1ON � . �AllTHO TiON.. � � � • � � � • � � . _ . : . : ......:�.�D��`�.:. �� . .. - � ��-�.- . . � �.=� � �� . . � .. � . uthorized State Ager�t � � � . � . � . • . � � � Date - � . �� : - � :.�: . ..� f .. . . .. . . . . .�� . � . . . . � Installed B�:_ � G � � � . � Date: • �'� � • a • .... . . :. ���. : � • .... .. ". ._. .. . . _ -�.• ' - . � --., • •... �.. . ......... �..:. - •-- . � . . � . ' � . -. � � � � � � ' . . :. . _ . � . . '" "..._ .. . . . : . : . . .,.. .�p � . . . . '� _ . ��i - .. . . . .. . _ . . . _ . . .. _ . .. .. :. q� � -� ... .. . „ .- . ... . . .. .� � . . . . , r� l . �.i . � �� � - . ���� ��� . � - � ��. . �. �� � . �� `�' ����� ��� . i�' � � ��' `� � ^ . i �-� , � ;�� �; �,• � �� � . �� � �� � 1 � �- .. _. 1 i7.� �j�� � . _ �� .� '� <<ee p `�-� _ ���, �m�� � �� � � � � � , �V. a7i2���2 � � �� � ���� �� �y11.a � �� �� ������ IE�.�.s�-�„ �,�,�„ ��.�,11 IHL��.II-�Ila Applicant: � Location: � ��x N1:��p � � � �rc�el = � � ' / S�u:bd:ivis�ian S� ;�� � i � Fh�s��Sec�t�i.oi,�:� at r � Oper�°t�on �Perrn�t � + � System Type (In Accordance With Table Va): . THIS SYSTEIUi HAS BE�M IidSTALLED IN COiViPU�►►NCE. �VITH APPLICABLE NORi'ii CAROLINA GENER�L STATUTES, RULES FOR SEIAIAGE �TREATi�iENT AiVD DtSPOSAL, ._ AND ALL COidDiT10NS Y.OF THE INiPROVE➢VIE�1T PERMIT �D. CORlS'�RUCTION � AUTHOF�1 TIOIV.. � � � � � � . . � : � . .... :�.�a � ��� :. �.:� �� .. . 2 3 uthoRzed State Agent � � � . ' . • Date � . � . �: . �: , . . . . . . , . . � _ ,� � �`a . � - Installed B�/: . � � � � . Date: � �p � - . : :-_ -:: ' . � �� �v � �� �� o �.�° `� u6' �� . . ���{z .� � �2 —'_ �� �� "'s"_�..� 7—�' PCH , rev� 07/29/Q2 ��� y _ _ _ _ ___ _ _ _. s��'1-�c ���� �ivs���c�d�� �r����.i$-� �-�� i� - � Ta: Ma� �� Farce! # 3� � System Type (Table Va) OwnedApplicant� �ubdivision � AddresslLocation SeclPhase Lot # St�ts ID/date �_� Capaciiy. � � Tee and Flier Baffte Sea[arrt Riser (ifi applicable) Tank O�rtlet�.Seal . Pemianent Marker � Purnp Taaa6c . . Capacity � � gal. . - � . � Waterproof /Sealarrt : . Riser . � � . Water Ti hfi �ump _ Gt�eck Valv�/Gate Vaive : . . .: . . Anti=s�p on o e . - .:... ... Floats/Swific�es .. � . . . Alarm�(visabie and audible Electricai Components Rate gpm Apprvved Pump Modei Bloc� 1lnder Pump Pump Removal Rope/Ct�ain. � Disf�3bu#aon System � Seriai Distribution ' ressure an' ol Low Pressure Pipe � Appr. Pipe Material and Grade Tnench Width "s, ft. Trenct�. Depth .. a � in. Trench Length �(�� ft Trench Grade _/' Rocic Depth and Qualiiy �/ . Dams/Stepdowns etc. -� Pressure Laterals . �' . .� . Hole �Spacing � .. . o e ize � � — . � Pipe Sleeve � —.. . � Tum-ups/Protectors . � . F�equired Se#l�acks: . . � . �rom Welis �: -- From Property lines � � � : Structures/8asements . � � � �-� it es rainage ays -.. . _ _ � . _ .- - Surface�illlaters Public Water Suppiies Vertical Cuts (>2 ft. \/ Water Lines � �/ Vehicie 7raffic , � Easements/Right of W< �her Easemenis Recordes� . e perator orn Cominer�ts� pc5d rev. 3!'13/a1 ������� • ���� �� ��' .�r,�— � � �J � 1� � I����-�� � ����.11 I�I£��.I��I� WE� PERt��'� . i'�SE SEE �'�"�A�3�D P�lV ��3It WE�..�. SY'I'� ����J'i 3'� � 'T�xx Map #: � �_ PaYce� # _�� 'I'omnsiaap. hs � � �� �8� s,�aiv�o�: �rT c� Q s�o�.: .�:;, : �, ; '��I , - ,,, ;,, ': , ' • . . . i • n �, . � ' + l�e�Ba�'effiega�• Site Approved by C'��"� 3- a�-�3 Grout�ng Approved bp � � 3-,�8"-�3 Well Log -�- - Well T Ait Vent � Hase Bib Concrete Slab We� DY�r: d � or-Y, `� ' . W� �1ppn��. ��: I)��: ��'`�� � '�ee Attac$ae� Sit� S�s�*� Wells must be 10 feet from property lines. We1Ls must be 100 feet from septic systesns. Wells must be at least 25 feet from anp building foundation. Otizer conditions• - PCF-�, rev. 09/07/Q1 ��s �oo� ��� �._, : . � ���.� �� a � / 1% �� �/ � �� Jl. � � � � � �T Nt� l�2 / l ��-�s��,r,�, ����� ���.��� D�4o �6�10�1 3 -� 7-0� Owner: !�� ��, �/ Location: / �7 S Subdivision: lI4 K � '/.P �-l« ' ' ���( � � c�f L/'r� �r�'o�►'C L�g ��u vc Lot # Tax Map � ���% Parcel # ..3 ��G �l il/nf/1 Cr b� Qu�. t�Tr, c.^� Well Construction Distance From nearest Property Line (Minimum 10 feet) Distance from Septic System (Minimum 60 feet) Total Depth: � ft Yield: 2� GPM Static Water Level: �� ft Water Bearing Zones: Depth /C1� s� ft ft ft Casing: Depth: From v to �C� ft. Diameter: � in Type: Galvanized Steel � Weight: Thickness: .�g� Height above Ground: �G/ in Drive Shoe: _� Yes No Any problems encountered while setti.ng casing? Yes �o If "yes" give reason: Grout: Neat: SandlCement � Concrete GraveUCement Annular Space Width inches Water in Annular Space Yes No Method of Grout: Pumperl Pressure Poured ✓ Depth to _ Materials Used: y ,8�� No. Bags Portland cement r b��-� Weiglit of 1 Bag 5 LJ Pounds If mixture (san�, gravel, cuttings) — Rario to ID plates: ��Yes _ No 4 x 4 slab ✓Yes _ No Drilling Log Location Drawing From 'I'o Formation 0 7 li t� r�t< � � � � ,. � D D ��C �-�� �� U��� I� (� D 4 �'�r` l�' �� j�I,I� jy"I�LL �, l�.hU F� I hereby certify that the above iuformation is conect and that this well was canstructed in accordance with regulations set forth by the Person County Health Department. Signature of Contractor �D ID# a% �� .�_—,_�- Date .3 �T'�3