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IF THE INFORIIAATION IN THE APPl1CATiON FOR �AN IMPROVEil1ENT PERMIT IS FAL91R�. Ci�IANGED OR THE SiT� !S
ALTERED THEN THE 1MPROVE3NIEid'T PERMIT ANO AUTHORIZATTON TO CONSTRUCT SHALL BECOME INVALID
1, P�iIINL �Y�OiO{� L� (VRIiR�r�i� �1�: �(J m w. t1 !'i l� { i F! A.S
HOfi1e Ph0�1C .2 Fi �-I - �� S /„ � • /4id� .- ri `�I �rs.� �Lu r e� 1� rYt f i ( S �,,;��
81x1i1� �IOQO: ' � li,+�.� J,., � n
Zj Nam� and addcess of cutrartt owner. .�,Y. e
3) ProQsrty D�scripttocx Lot str� �. n b Ta�w� .�L�_
Di'ections ta the propatty (lnc�lnq road natifes s�nd tuunbe�s}:
4) Pcopos�d Usa and 3truct�tn DescrlpHoo: anawa eactt af the tonawlrp que�ona:
a� Proi�oaed �q 0
b) Slidc Bw'� Q Modular �. SLple W{de Q Darble Wide G�'
� Number af Bedroarr�s: � � Nttc:�ber of ocapat�ts� ar paopl� Oo be sewe� �
a) Base� Yea q No �-ti"yes. # of basert�nt ib�ucex
' A �e � Yes q No �
� 4�ioc�sof PtoQoaed Struc�ur+a: VVidttL ,� Deptlx �r
��� �PP�Y �IP� PcivaLs �(naw Q or aodaWg aj. Publia 4 Coam�a�Y 4 Sprinq �.
Aro any w�lls on a�oining p�opett�/� Yes a No C�ttyes, loc�tion
6j Pias� Indicab D�aii�d Syatam'fyp�: (systema can be ranbd 1n ctd� af Y�' P�i
� .�cCivestlo�ai Yodifted Com�atlonal _ Atbnutiv� �
_—�hP�YI=
CLEARL.Y 3TAKE ALL CORNERS AND LiNES OF THE PROP�RTY.
STAKE THE CORNEiiS OF ALl. PR�OP08ED STRUC7U[t�S.
P�EASE ATTACti SURVFf PU1T OR SRE PI.AN TO'iH{S APPl.iCATION
��Y �� tc tt�e Pe�on Caunty Health OaQartr��t 40� a s�e av�lon tor ths ati-siie sawapa dbPoaal syst�m
the above-dssaibed p�pecty. t a�tee fhat the co�a�ta af this aQplicatlon ace trus and �etst the ma�artu�n is� tA
Pi�ec.ed on the propecty. ! undecstand if the si�e b altered a ths i�mded us� �. ths pam$ shaY beconts invttiid. l tu�desst�
th�t as app9r.� I am t+espans�bis ta ida�iiymg and marbn9 P�'�Y iinea, c�mac� azd making tha ai6e a�bis far
petaoenal of Pe:son County Heaqh Dapartntetrt to condu�ct their avdtmtloc�s. I ta�scatand thst ! am t� ��9
Heaith D !f my p�+opaty Go��t�ir}� any watlanda as daiq�ed b!f ���l �'Ps ��s-
��-� 9-aC- o0
Owne� Repsast�ive . oa�e
0
F�
��#�St3Rl GL3lli�ITY ��1V1R�NME�YTAL i�E�Ai�Ti�
ran Nap � f"1"T�% P.ewi i � v�- I
m�, � T� �l a+ � �� �e.r -.
pppr�� Gi h1m E w�.� n S ..
,.� 15i s p,� 'c� �l�i ��0.�. Q r f2
� � .�saac`s "5',�.i l � �
su�� a ��� s.� ��_
� Improveme�t Penni# .
A huilding s�enr�it can�ot be issued with oniy an imorovement Psrtnit
New � Regaic Add�on Type of Struc�us sF D� Water St�pQly �� .
# of OccupaNs �•af 9edrooms � Oiher
Hasement? No g� F'�� ��
Projeded �a�1y Row: �$Q g.p.d Penn� Valtd Fcc: �ive Y�rs 0 No Expicatlan .
PrnPcsed �er Sy�m �'YP� Gaizv et+:-(�o�o,,/
Pump Required?' Yes k� No� . �
Proposed Re�air : � ue:t��� � .�
Pem�it CandBionx S�'2 e h sc� s:�.. � S�mn� �,r: I d�►� -�µ,,�art "� a,,,�� �ld �rzn. v mPe�lr� � ke.
�n s-%. �� e�'f' n✓n n f r G� (%��PQ ���o wr„ 4 P� h�a u r.
� • /
Owner ar Lex�al Represe�re �� �: �!��� z—
Authorized State Ager� � p� /� eti0 0 0
The issuance �ef this p�rsnc� hy tt� Healttt Depactrne� 1n no way guarantiees !he issuance of ottter p�rrn�s. The pecm+i
hatder is respansihle for ch�g wiih approprfaba goveming bodies In meeting the�r �b. This site is
subject to revocation if the sibe plan, Pla� or the it�teaded ttse changea. The fmpr+evemerit pem�it shall �wt be
affected by a cf�ange in owne�hip a! the sibe. This permit ts subjec! to camplianca with tha provisioos of the
Laws arid Ruies for Sewage Treatmerrt and Disposa! Sysbems of the North CaraMa Adminlstrative Ccde.
Type ei Waffie+nraber System !/�nV B�►�o �t,r �� f(� ��
�y TyP�; ��r. S�_. t�ew s�1'' Reaai� aE�ansian 0
8asement? 0 Yes No Hasement ��dw�� t7 Yea�d'No
Wastewatac Svstem Reauiremenls
, SepHc Tardc S'ize: COao ga9ona pump TaNc Size: `— gadans
Total Trencfi Length: �l D feet Ma�dmum Tren�t DeptK I� i�es A98�'89� �eP�� �-
M�dmum Soil Cover: � inc�es T� SeparaBan: � Fe� on C�r
. Pecmii Exp�atian Date: a� D�
Authorized State AgenC p�e; . . � .
� The type af sysbem permitted 0 doe9 Q do nat. dtiter from the type specifled on the applicatiao. 1 ac:xpt
` the specificatians af this permIt
.. OvmerlLegat Represer�ative Stg�toe: �''�/ ` pa�: 3�� Z '
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• PC}-1D, rev.11M8/99
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P�P:�3�@[4 �Uilt'S/ ��,�1. �A�l�4i10I1t . I 1 1 O
�Se�ir+�nmeniaa Hesith Sectior� Tax �AaP � .
. . Paresi #: � .
- - : SiEi S1�ET'C� � . ..
h s • ooc�Gri a4 e�GfC S/ C-b 1(01
ct 1� � � Subdi�ision/SedionlLoi#
, �,2 a.o 0 0
,qgerrt D
����� �pp�e ca�torrrs o,rty. T�r� ca�rdwdor m�. f� the s}'� -
� m��e �� to ia�m+e t�t �r�de i� era�
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���a�s 1+�.,;� ����w
S��o`k�' �� ���a�,I
S��f`cr S�s�r,,, ��
`a � �hC�h G��/h
�Yl'LOt}CimGtl'h
�„s �!( at prv�er 9rac�� -�,l�ow,�
COh(Dur.
�-�cf �� �ava. bu���dikq .-�u,..c�Grl�on
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Zoning: Townshlp: • .
9�bdWtsion: � • • Sectlon: � L.ot: �l
A�pU�can� t ��
Location: �,�rf-� � .
:
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C�p�ration Perrr�iit �
. . System �'ype (In Accordance With Table Va): ��
. , _ _ .
THIS SYSTEM HAS BEEN INSTALLED (N COMPL.IANCE WITH APPLlCAHLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEIAIAGE TREATMENT AND DISPOSAL,
AND ALL O DI'110NS O� THE IMPROVEMENT PERMCT AND CONSTRUC770N
AUT�iORIZA
• � ' . � . , �r � �� `�
Author¢e State Agent Dafe
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PERSON COUNTY ENVIRONMEidTAL HEALTH
PLEASE SEE ATTACHED PLAN FaR WELL SITE tAYOUT
7ax lWp �
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�� � Tawnship �� �'� �\ v Qr
,�� �a mm,H w�� i�s .
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Subdlvisioa .
Tvae of Water SupplY:
Reauirements:
W@ll Permit
✓ Individual Community . Public
S'�te Approved by � '� . �
Grouting Ap v by -d�?
W Log �
ell Ta � � . 1 � �.�� �q Z�a'3��� -
. J �S
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A� �
Hose Bib �
Concrete Stab '
Weil Driller: ,
Weil Approved By: Date: �
'"'See Attached Site Sketch**
Welis must be 10 feet from propecty tines.
Wells must be 100 feet from septic systems.
Wetls must be at least 25 feet from any building foundation.
Other conditions:
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PCHD, rev. 11/29199
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���`,�.�f ���� �� D�Oc�� OD � o
`_- -,- c� � ZC.T�T�P�Y ° ° � a�..�.� �J
I�sa�is�aasxa�aa��.11 IF���.71�I�a. � � ' ° ��g ��
Well Log
p��; ;� � Ma ��%C� Parcel #
I.�C�i1�A: !' j`. l . (�� !i'l �i ��1G. � ��r�� c- �//".• �4 �'� �ral /
Subdivision: 0��� dlG-� %�c.rc5 " Lot #
Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from Septic System (Mini.mum 60 feet)
Total Depth:%_ ft Yield: �_� GPM Static Water Level: � ft
Water Bearing Zones: Depth ft ft ft ft
Casing:
Depth: From �_ to �/ ft. Diameter: � in
Type: Galvanized Steel
Weight: Thicl�ess: .� Height above Grouncl:1� in
Drive Shoe: Yes No Any problems encountered while setting casing? Yes �/�To
If "yes" give reason:
Grout:
Neat: SandlCement �� Concrete GraveUCement
Annular Space Width inches Water in Annular Space Yes No
Method of Grout: Pumped Pressure Poured Depth to F�
Materials Used:
No. Bags Portland cement Weight of 1 Bag Pounds
If mixture (sand, gravel, cuttings) — Ratio to
ID plates: Yes _ No 4 x 4 slab _ Yes _ No
Drilling Log
Location Drawing
From To Formation
C� �% c/ : �
7 g2
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. 0�` �
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w�,��y
I hereby certify that the above information is co ect and that this well was constructed in accordance with regulations
set forth by the Person County Heal Dep t
Sigaature of Contractor ID# s?>��?l� Date ��;�,�-� 2
. PCHD rev Ol/16/02