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A40 350`� � � q �7_66 . . • ` �-� ��_�" ��a.00 a b �}2� 3 0 3 .6 s ' • LS '"L �� �Lll _!1 . .- �t!t �L� . � i • i� ' �►1! �S� � ..�_ • : �. . 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, , � , ' . _ - ��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 �: � � � 14ETC� � . . _. - - ��� ��. _._ ___ - � c� ,�r1� s . �a �� j��S Cf �- � a-- � � • �o� ot� �► " � �� �� �r. �,i�/ , , � � � . .._.. �'-_ � - � . : • _ = 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 `T , Ssc�a-c s nt,� ( , _ �> _ , w��c� ,���� I ,� . ��� _ �0 rw G s` ` ZB,�x��' Ser�� �s-�e� � ,� �n t�ouse q,�— �V'o P er ra.�te �o �� ow ► K 5 9 � �-f-�u� � � — � �' �l Ylr��.X i muV►� .� � Se,��`c, ar� a. , ��n � � � �c�M ��' a�av� ov� 's P� e. � 9 S�: l„�So' � ��� � _ � W. � � 5�v� X 3� Gian ven-��� � Se�-fi� Sysf�� �I� � �� � - w l� t'�v��mun, �hc�.cfA�,� CD NV e h-�-1 o hct' �2(��r r- �� �- � �� �� P� � � : ,� �. w �� � �� � ,.«. 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 ���� � � 1 , - ` � � 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 �..