A40 350`� � � q �7_66
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IF THE INFORMATION IN THE APPUCATION FOR �AN IMPROVEi1�ENT PERMiT 18 FAL91R�. C�iANGED OR TH StTE IS
ALTERED. THEN THE iMPROVEi1AAEiV'T' PERMIT AND AUTHORRATiON TO CONSTRUCT SHALL BECOME INVALID
1� �!!I� �Q1ii� �iy` 1�1111i��Ch�ii"!'�`w� OW1�0[�: �' vrim � r I�if �.'1�+.t✓�4
Homs Pttion� � l, i-! -� c c� � 14d� _5 ti S k!< o �,�� 6, ;,-, ` tis ��,
8:i�i� � �� �Y'C9`y %`"!.n� n
��iiRl� iLtt� i�[Oii O� Ciil'lORt OW[Nf: JG•r+�T
3) Prop�rty D�scriptloc� Lot� l, ao Ta� FiR_
Directtone to the ProQert�i (irtic�ding rnad nantes and ruunbe�s�
4) Ptaposad Uaa and Structtsrr D�scriptian: anawa eac� afthe fdb�W que�ocm:
ai P�OPoaed C�E�q ❑
b) Stirdc Buat q Moduiar 4 Skq�e Wlde 0. Doubie Wids �
cj N�unber at 8edroo�r�a: � j. c� Number ai o�nb� or peopla to be saNe� �
a) Bas�C Yea Q No C3'�'yos. � of basetnant it�ucex
' 4 Ga��Qe � Yes q No 0�'
� 4�onsof Ptopoaed Strz�cttus: V4idlt�: 2� De�,so
� N►�+' �+PPhI �IP� Prtvais Q(new a ac aodatln9 �. PubYc 0, Comm�a�► o. Sp�in� O.
Ars any we�s on adjoi�ing p�opat�/? Yes 0 No l'�jros, loc�tlon
aj Plas� Indicat� D�sii�d Systom 'iype: (syatems can be r��io�d in ��drr of Y� P�)
✓Conve�ttlonal Yodifted Canv�ntiatial
Ottwc (Sp�d[y):
—� �
CLEARLY STAKE ALL CORNERS AND I.iNES OF THE PROP�TY.
STAKE THE CORNERS OF ALL Pi�OP08ED STRUCTURES.
PIEASE A1TA►CH SURVEY PU►T OR SRE PLAN TO TH{3 APP�ICATION
��Y �� to tha Person Ca�mty Health Dapartrt�d ibr a s�s av�klatlon ior the on-ai�e sawaq� disPosal sYs�sn
tha sbove�ascribed propa�ty. l agroe that the �ts af this appiptlon acs ht�e and ttipcment the t� �a b�
P�eced on the p�oQecty. t und�tand if the s�e is altec+ed artha ir�Dended tw ct�tpea the pe�m� sttaY becotne inva�d. I undes�t�
lttat as ap�rrt� 1 am cesporo�e ia identiij�ing and meriang P�ope�tY W�ea. co�ners and maidng the site aax�le tac
pa�on�t a� Pe�son Cainiy Hesilh Daparimetrt tn condt�ct i�eic avakmt{otu. l tat�tatand that 1 am r� ��s
HeaBh D If my ,��► wetlanda as desi�ed b�l the AcmY CorPa of �-
� � a� �
o� i..�+ �.�u� . o�m,
,
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_ - ��LE.�:
Tax �Iap �
P��St3Rl GL3UNTY E�iVfRONME�ITAL l�E�1i'ii-!
Palcdi
3�0
- zcoinq � raw�ip � 1 s•�' . � i V ex' -.
� -. AV+�m w"�-�nS ..
,
,� � 57 s � `it �►J � ` �a�C , Qu� r • r i'e
� � �sc�ac`s �',r�o�. � '
s,m�„�� ��t � �_!�
� improvemerrt Permi#
�
N� `-��� � a� r,►r� �s�S� D� w� s�a,r �le
� o� o� �� B� � ou,�
a�r...�, e�,� F���
Proje�ea oaly Row: ��g.�.d. Pe� va�a�t' c
pnpposed� Tj�p� COn v'�nt�?�n,
Pucr� R�d?�
Yes k - Nq
prnposed R�it ; C-on v'�2n�na, ( /�
Permit Canc�ion� / pP S�r t� �ro �
�Rr
ONo�
e� h a toh GL� �o!
:��r � � .
o��� R�� s�: a�: I� "�`o�
a,�,o�a sc�a� � n�: a-�J oa
The is�ance �of ihis perm� by the Heanit Oepartrne�rt In no way gtmtar�es the issuanca af oihu p�s. The �
holder is respcnsihle for ��th aQptoPclabe 9aveminq bo�es ln me�ng thdc' r�uiranertb. '1't�is siEe is
subject to rawcatiort tf ths siba plan, pMit, or the intanded t�e cf�a�ea. The hnQncvemart Permtt atnU rrot be
�d hy a cl�ange in owneiship cf ttte siha. Thia pom�it ts subj�c! to compti�nca wlth the provisioas af the
Laws arid Rules for Sewage Troattnerrt and Disposal5y� cf fite Ho�th Caroiina Administrativa Code.
Authorization To Consiruet Wasfie�water Svstem (Reciuired for�Buiiding Pemiitl
Type oilN�ewaier S�rstem (� h veti►�a� �.a.' 1Maste�waiex Flcrr 8D .d, ..
gr_ S.'��_ .
8� r�0 Yes No � ��°�'�rm �
Wastewatier Svs�em Reauinemanb ' ' - • '
. Sept�c Tacdc �¢e: / fl o c� � Pump TaMc Size: ga�ons
Tatal Trenctt Lengitx � feet M�nun Tr� Deptk .L__ �es A�e Dep�L In-
Maxirtwm Soq Cover: � ind�es Tne� �on: � Feet an Car�
Pamii Exp�atian Dat�
Ac�harized State Agec�
;ZO/o
Date:-���trd
T1� iYPe � sI►� Permi�ed Q does Q doQs nat. differ irom the type specified on the appqcatiae. I aa:�pt
the specifa�ians of t�s pariait
Ovmerllxc�al Re��eset�ive Sigrt�ue: ' p�: � � .
• • PCND, rev. 't'1/18J99
S�hs�,(I
..__�—._ _.. _ __..._....._._...__._..... .. _.. .
P�rs�n Caunfiy 9�ealth. Departrnent
E�vironmeniai Health Seciion
Tax AAap #: �7 v
Parcal �: � �
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- - ��� ��. _._ ___ - � c� ,�r1� s . �a �� j��S Cf �- � a--
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Sy�n coa�po� nepr.esent appraxi�le ca�ttnws o�tlj. Tbe ca�tradar mr�tt, flag !he sy.stms
pr�or to � llis installador� to iiuure lba�t proPar �rade is ewirrtained
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Ser�� �s-�e� � ,� �n t�ouse
q,�— �V'o P er ra.�te �o �� ow ► K
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.� � Se,��`c, ar� a.
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Person County Health Departme�t
Environmental Health Section L�G�' � �Q
Tax Map #: Parcel #:
Zoning: Township: ,F�� f'� � V �f
Subdivision: i�� Section: Lot: � d
Applicant• (Yl � � nS �
Location•
Operation Perm it
System Type (In Accordance With Table Va):
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
AU ORIZATION.
,�� l� f
Authorized tate A nt Date
��
, �l ���� �
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` � �
I �
s'�'Iz.
v
Tax Map #: Irl�-YLJ Parcel #: �-/� �
il
PCHD, rev. 10/12/99
0
PEi�SON COUNTY ENVIRONMEAITAL HEALTH
PLEASE SEE ATfACHED PLAN FOR WELL SITE �AYOUT
���
��c, � �.,� .� 3��
�,,,� � . T�,, �' o��f ��ve,r _
�
�
, �.
�,. �� � - -
Tvae of Water Suaatv;
Weit Permi# ' �
✓ind'n►idual Community . Pubtic
Reauir�ements:
Site Approried by ��� i . -
Grouting Approv by ' � Ld �j
Weli Log J
Well Ta � " �
Air Vent • •
Hose B�
Concnete Stab
Welt Driller: -
Well Approved By: ''`�� �"
�
n�: 1� J t�—�' (
"See Attached Sifie SiaBtch*'
� We!!s must be 10 feet from propeEty lines.
Wells must be 100 fe:et from septic systems.
Wells must be at least 25 feet from any building foundation.
�
�
Other conditions:
�
L
7*
�
PCHD, rav. 11/29/99
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date:�o-//-o/ '
� Owner. Fi< <�0�1
Location%Directions:
SR#
� �
�
��d�=
Subdivision �Name: __ � r; � � Lot # ��
Drilling Contractor: � � •�c
WELL, CONSTRUCTION
Distance from Nearest Property Line 1 v Distance from Source of
Pollution t G a
Total_Dep.th:� /�/C� Ft. Yield: / GPM Static Water Level aS—' Ft.
Water Bearing Zones: Depth �Ft.L�/�Ft� � Ft� Ft.
Casing: Depth: From 6 0`3`i Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel
If Steel, does owner approve: Yes No
� Weigh� Thickness:�_ Height� Atiove Ground: /�i Inches
Drive Shoe: Yes ✓ No _
Were Problems Encountered in Setting the Casing? Yes No �
. If "yes" give reason:
Grout: Type: Neat Sand/Cement / Concrete �
Annular. Space Width � Inches
Water in Armular Space: Yes No
_ . _ Method: Pumped � - Pr;ssure � Poureci � - �
Depth: Fr�m O to �, C� Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes � No � = �
� 4 x 4 slab Yes � No
I HEREBY CERTIFY THAT THE ABOVE TNFORMr�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON CO`vi�ITY HEALTH DEPART E .
ro- �-oi
ign ture of C tractor Da�c
�..