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IF THE INFOR111WT10N IN THE APPUCATION FOR �AN IMPROVEiIiENT PERMIT 13 FAL91R�. C�IANGED OR THE Sil'E !S
ALTERm THEN THE IMPROVElV1Ei�IT PERMIT ANO AUTHORtZAT10N TO CONSIRUCT SHALL BECOME INVAUD
�) P�rmit nqwatied bll: (Owaerl�9�tlpr+ospac�va cnwner): �a m�.f, �, W�„� k; � s
Hort10 Pt1ofl� 2 4, L� -'�_ S�� • A� S rd �,. r', J IJ �. r,J 1� m.• �! S i'��
B1i3�10� PhOI�: r� ' 1�F:7 H���
Z� Nam� i11d addcbss of cums�lt Owner: ��. «�-� r
3� Prop.rty O.scriptic� l.ac � �,,3,�. Ta� �%1..
Dinedtons to tha ptopecty/ (1rc�ud6� r�d natttes and ruitnbeisk
4) P[oposad Us� and Structur� Dacription: anatiwe� esch at the foBo�winq que�ona:
� �Po� R'E�nq 0
b) SHdc Bu� �. Nodular q Sirpie VYtde Q Double Wide �
q Numher af 8edtoaisa: �,. � Number af a�nts ar peopla Uo be socve� �
a) 8a�emernt Yea q No 19�yes. � ot basemant �bucex
'� GarbaQe DKposa� Y�s q No @�"
� q�ions of Propoeed Strucbura: VVidtl�: � s' Daptlt /�
aI ��PPh► � Ptiv�a Q(new a oc s�ds4�o Cq. PubRc 4 Caacn�a�r 4 sp�nq a.
Ars arry w�spa on a�oining propert�t Yes 0 No (�t'fjes, bcation
6j Plas� Indlpb D�sii�d SYsi�m Tj�ps: (syatama can be r�uibd 1n ad�r of Y�' P�l
�Coitvattlonal Yodified Conv�ntia�al _ Atb�ttvr �nnovat�w
_�«'hP+�hl1-
CLEARLY 9TAKE ALL CORNERS ANO 11NES OF THE PiLOP9ZTY.
3TAKE THE CORNERS OF ALL PftOPOSED STRUCTUii�S.
PLEASE ATTACI�i SURVEY PUIT OR SRE PUW TO THtS APPUCATiON
��Y �� to the Pe�san Cou�ty Health DaQartrne��t i� a s�e av�uaUoc� tor the a}si�e sewap� dVposal syst�
ths above�dasa'�bed propaty. t aqtea tl�at the c�r�tanb af this appll�lo� a�e tnss and [�fi the Rf�ornum iac�tles bD
p�aced on ttte p�opecty. ! uadecstand if 1he sibe is alt8red crthe �sDended teu rhanpes� the pandtshaY beco�te inw�d. I unde�st�
fh�t as app6cant, 1 am c+espons�e for tdart[iying and maridn9 P�P�Y i�. �� and maidng the ai�e a� +ar
pecaonnal the Person County Heaqh Dapartmart to canduct tha�' avakmtlons. I ta�atand that 1 am t�pans�le f� �9
Heaah D if my �s any wetlanda as des�na�ed bY the Armll �Ps ��s-
�
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0� t� ROQf�!llf8tlV0 . 08RA
P�#�SON C011NTY ��1VIRONME�YTAL l�EAL-TN
Ta: llap i� /" �-( � PatCN il
Zoninq Township r ld,7 �1 /�1�e1' '.
ppp��,C Sqrnm f-�qcwk.r�,5 •-
��: 157s 1-�u.� �_��-- �/1/►`� �ot� � ����f
�
�
s„�o�: �►lcv�'�l�� i4� r�s s.��: ,.� �q
Improveme�t Pennit � ,
�
A buiidinct �ermit cannot be issued with oniy an imarovement Pennit
• New `' Repair Addition Type of Struchue ��� � Water Suppiy 1� e l( .
# of Occupants #•af Bedroom�_�� Other
� BasemeM? �Vo 9�seme�tt Fodcues? _�o .
�
Projeded Daily Flow:-�ld'il
Propased Wastewater SystE
Pump Required?' • Yes
Proposed Repaic : or, U¢
Pem�it Cand�ions�.-,�e
�r�er �hS�t�� A�
Owner or Legal RepreseMattve
Autharized State Ager�
Permit Vatid For: �fFive Years ❑ No Expiration
_ Cohv2r�.f�bna�
� I�Il�h -FlGlw�a lLO h , G'�� .lO(
�e ��owi n� C-o �. � vc� r-• �
i �
Date: � -� Z-
Date• j°Z � 6U
The issuance of this pemut 6y the Heatth Departrnent In no way guarar�s the issuance of other p�rrrnits. The permit
holder is respons�'ble for d�eddng with approprtate govemi��g bodies in rttee�ng the�r requirements. This site is
subJect to revoca8an if the stte plan, plat, or the int,ended usa cl�angea. The tmprovemant Permlt shall not be
affected by a change in ownership of the site. This pertnit ts subJect to eomplianca with the provisions af the
Laws and Rules for Sewage Treatment and Otspa4al Systems of the North Caroiina Administrative Code.
Type of Wasiewat System (,d/7 fieh�Ci �� Wastewater F(ow���
w
Fac�ity Type. !�i :.S'F Q. � Naw�i�epait oExpansion ❑
Basement? � Yes fd No Basement Flxiures? 0 Yea j�1 No
Wastewater Svstem Reauirements ' -
. Sept� Tatdc Size• %(l�l� gaitons Ptunp Tank S`Ize: ' gailons
� � �
Tatal Trendt Length: __�1� Maximum Trench De� �_ inches Aggregabe Depth: �� in.
Maximum Sai �o er: 6 ind�es j Tr� SeparaBon: � Feet on Centar
//
Permit Expiration Daie: � ! � � 0 �
Authorized State Ager� /�-d`��i(AC11Z
The type of sysbem permitted Cl does Q
the specificattans of this permit
OwnerlLegal Re{�resentative
�
�
e
r Dats: i� �O � .
nct. dlifer from the type specified on the applicatIon. I acr.2pt
Dabe: 4 �_O Z—
PCND, rev.11/18199
,
. . .__--.. _.. .. __... __.__._..._.__. .... . . --- �
�P�rs�n Caunty 9ieaith. �Departrnent �/
� E�a�rironmeniai Heslth Section . T���ap $: . 7a�
_ . . � � P�rc�l �: � . .
� S1'� Sl4EiC� � _ . . . _
_�` kr�c� �-of 5.R
_ . �Ctrnrn � w �n5 � a
U Name ubdhrisioMSedioNLat#
, ( Z 20 p C�
. AuthoriZed State ��e � � .
,�y�n copipnrre� npr.esext appraur�e c��turaa only. T�i
pr�or fo beg�i�ur� tlis installation �o inture that Propu' X�'ade
w�l 1
�}Y�2L�-'�
�
�rs�+ � �2�'G S � 9r�Yh at,�— � � �e.r
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w1 ��� vr►u w� �o ►w -� o u v��� a,` � o ri , a
( d� Vh i vt �"�'►,U.vh -�1`oyK 0�'o ��e.t�`�� ( i v► es .
. a �
�e� Se�► 'C, $' S�A�tM SD � rni n i vw,u►n
�
�� �� D� �pn�.
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Scaie: j `` = �TJ r
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` �' PE�tSON COUNTY ENVIRONMEi�TAL HEALTH _
PLEASE SEE ATTACHED PLAN FaR WEi1 SITE �LAYOUT
T�x ,Ihp �
---�-��. . �� 3 ��
��� - T�p . ��=,�� ve� �
,►�,u� �n� ac✓�u �r .
�S7 S� j�i�� i� S�' �/�/i"id+ l�C�� �I/tkrf�c-�qu.� _
Loe�on: ,
Sub�ilo� ` � "'v� \ � � �� . � T
. Weil Permit ' �
Tvae of Water Supalv: Individual Community . Public
Reauirements•
Site Approved by ✓ � U$-1 �-0 Z
Grouting Appro ed by -2 Z
Well Lag �/.- � ' ?i
Well Tag�_ � �
Air Vent `� � ( 3-02 .
Hose Bib �
Cancrete Stab '
� Well Driller: l�, n I��j, �� ( t�U���._
/`����%I l,��M Date: �—( �—(��?,-
, Well Approved By: ,,
�_
"'"See Attached Site Skefich**
�� Welts must be 10 fee# from propecty tines.
Wells must be 100 feet from septic systems.
Welts must be at least 25 feet from any building foWndation.
Other condi�ons:
R
�
�
PCHD, rev. 11/29199
d
���.5� ���.��� ��oo� 230
`� ' '"� c� � �C.T1�'II� �Y �p� a� .� f �n�1�0,�J� �C
����-�������.� ���.n�� � D�o Dr�Dood - �z-� Z
Well Log n
Owner: �� M� �UJ ku1 S Tax Map lv �� Parcel #�34 �
Locarion: �
Subdivision: (J - —S Lot # �
Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from Septic System (Minimum 60 feet)
Total Depth: �� ft Yield: Z 5 GPM Static Water Level:
Water Bearing Zones: Depth � ft r� o ft ft ft
Casing: �
Depth: From
Type: Galvanized Steel
Weight:
Drive Shoe: ' Yes
If "yes" give reason: _
Grout:
0
to �� ft. Diameter: �o ��i in
_ ✓
Thickness: .18� Height above Ground: in
No Any problems encountered while setting casing? Yes No
Neat: Sand/Cement ✓ Concrete GraveUCement
Annular Space Width �_�hes Water in Annular Space Yes No
Method of Grout: Pumped Pressure Poured ✓ Depth � to �� Ft.
Materials Used:
No. Bags Portland cement Weight of 1 Bag Pounds
If mixture (sand, gravel, cuttings) — Rario to
ID plates: ✓ Yes _ No 4 x 4 slab i%Yes No
Drilling Log Loc�tion Drawing
From To Formation
R�'TO RAJ CA, P�ix�O�
( Z.Z � �bu.
11u( 1�ZS
��
I hereby certify that the above information is conect and that this well was constructed in accordance with regulations
set forth by the Person Coun Health Department.
Signature of Contractor ID # � � Date S�"�� a Z
PC�ID rev O1/16/02