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Perso� Courttv Health Deoartm�nt
F�nviro�merthl Heaitfi 3ection
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IF THE INFORMATION IN THE APPUCATION FOR�AN IMPROVEiNENT PERMIT 13 FALSiR�. CHANGED OR TH S1T� tS
AI.TEftED. THEN'THE IMPR01/E3UIEi�1'T PERMtT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALlD.
1) P*rndt nquasted by: (Owrtsdagont/pcosp�ctiva owne�: �� �..� ..� �-d,-E �.� kc., �
� }�iOflQ'. �� � �'1'.� � L, �, ' A� t �'�,ri F�'-t, �r,! !I m! If < t�C-,�.
B�ti�l0as Photlo: �t � i� r^d 6,oraa
��iRl� a[K� i�[Oii Of Ctit'�� OWRer: s�� m-�
3j Propatjr D�scrtQtio� �ats� 1, oG, Tc� _F_t:i
o�ec�«� �o �e �v ��w �a �e a�a �x
4) P[apos�d lJs� and Stntct�trp DescrlQtian: anawa ead� af the fo0owirW qu�iona:
� �i�� 0.� Q
b) Stidc Buit 0. t�oduiac L. Si�nsie Wfde Q DauWe Wicie �--
q Number at sedroomx � d) Nu�er af occupants. oc peopla m be ssnrad: '
a� Ba� Yea Q No �yea, � of baaemart fix�uex
� t� Gaci�aaQe Dtsposa� Yas q No �'
�I q�iotvaat Pte�Osed Stnx�tuo: V4idttt: �g Deptt� �
aI Wa�� S�phl Typ�= Prtvaoe q(naw � ar aodaW9 W. Pu6�c 4 Co�nna�Y t], Spdn� 0.
Aro any weaa on �o�g pcopary? Yas � No l�}-lEya, iocsUon
6j Piass Indicad D�sii�d SYstam Type: (syatema can be rac�ia�d 1n o�d�r of Y� P�i
�Coaventlo��a�l _Modifted Convsatio�sal _ A�Iw ,�novativ�
Ott� �:
CLEARLY. STAKE ALL CORNER9 ANC L1NES OF THE PROP�R7Y.
STAKE THE CORNERS OF ALL PRpPOSED STRUCTURFS.
PlFJ1SE ATTACH SURVEY PtAT OR SiTE PLAN TO TH{S APPIICAT[CN
I he�abY make a�B� to tne Pecaoc� Cou�j/ Health DaQa��ent i�oc a a�e svak�lion ior tns on-d0e sawaps disPaa�t sys�m
ttw above�desa�ed propecty. l agree that the co�t,enb of this applkattot� ace tn� and �ant rite ma�oRu�n �tea to
Ptacod on the pcoQecty. 1 undecstac�d 'd ths s�e is alteced ortha i�ended t� c�attqea. ttte pemt� shaY beconts inwitd- i tu�d�
tha�t as apQikarrt, 1 am rosp�e fa ida�tiij�ing and marldn8 ProPettY linea, catners and tnaldng tt�e si�e a�s toc
personnd of Person County Heaqh Oepartma�t to cor�dud tt�ir avakmtloc�s. l�atand ihat 1 am t�pon�e for nat�n9
Health 0 eni fi my pc�ly� an�► wetlanda aa d�0ed bY the ArmY Co�ps oi Es�pi�-
I � �� �l �o
cr l.eqal Repreasntative . oate
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Tax Map #� Parcel # _ � �3
Existing Sewage System Report For. �obile Home Replacement � ,��� �
Addition Type:_ � � � �'
Requester. 4`�i VI � Home Phone#
�� �S� Ct�i �Q tY Business # � v" ��
��1�,�aQYD /II�- C�i���� �
Original Permit Located: '�S Water Suppl����
Septic System Designed For: �Residential Business Other
# Bedrooms � # Employces Other
System Type: � Jr�i�. Tank Size: ��� A' � Nitrification Li.ne: `�-� �'��
I r b -
Date Installed: �� �`l�'d � Certified Operator Required: � r�
On-site wastewater disposal system shows no visual signs of malfunction on � ���4
Permission is granted to: \ 01�Sd'Y't,t,C� �d c�- 3v ` w�-� c b��� '
Environmental Health S ecialist l./� Date: � 1,� o�—
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SITE. S��TCH
Name ��' - � Tax 11?a # r � �� Parcel # � �3
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Sub ' ' 'on � Section/Lot#� G� �
n�, _ �-- �--d�
Authorized tate Agent � � Date . �
sy� m�a� �� �p����� �y. The costtmctor »sust, flag the system jirior t.�
begarnzng ihe instaAu�ion to i�isrsre that�iropergmde is r��snta�sed
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PC.I3D, zev. 09/12/01
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PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAYOUT
Tax Map #: ��, Parcel # 3J 3 Township ��LA��T � 1 V�� PIN
AppUcan� � nn,w� �� s„ban►is�on 0.4�L. � ��� w�s�secnon �o� 105�
Locatlon• �5 �S
Improvement Permit
New '� Addition Type of Structure Water Supply WE�.-�-
# of Occupants
Projected Daily Flow: _
Proposed Wastewater
Proposed Repair.
it of Bedrooms � Other System Type � t
S� g.p�i. , Permit Valid For. Five Years ❑ No Expiration �
Permit Condi6ons: , f.��� Q,S/ L�D�rDc�.! � c �^ .�i� �
Owner or Legal Representative
Authorized State
Date: % � r � a _ `� (
Date: '� ' 2Z � � Dd I
The issuance of this permit by the Health Depariment in no way guarantees the issuance of other peRnits. The permit holder is
responsible for checking with appropriate goveming bodies in meeting their requirements. This site is subject to revocation if
the site plan, plat, or the iirtended use changes. The Improvemerrt Permit shall not be afFected by a change in ownership
of the site. This permit is subject to compliance with the provisions of the Laws ared Rules for Sewage Treatme�rt and
Disposal Systems of the North Carolina Administrative Code.
Authorization Ta Constru�t Wastewater Svstem (Re4uired for Buildinq Permit)
WastewaterSystemDescription: ��1� WastewaterFlow: <<•_ sa.p.d. Type: 'f
Facility Description: ��� c.,� i � D� New � Repair � Expansion ❑
Basement? O Yes Q�tQo Basement Fixtures? 4 Yes o
Wastewater Svstem Requirements
Tankage: Septic Tank size �OOD gal. Pump Tank size � gal. Grease Trap size — gal.
Trenches: Total length , ��' ft. Trench wdth _? ft. Total Area ����' _ sq. ft.
Max. Trench Depth: �Zl� in. Aggregate Depth: 1 Z in. Soil Cover. �o` in. Trench Separation �ft. on center
Permit Expiration Date: g' Z Z- Z� d(p
Authorized State Agent: Date: �'' Z'Z ^�a�
*See attached site plan and addendum page or additional permit conditions.
The type of system permitted ❑ does ❑ does not differ from the type spec�ed on the application. I accept the
spec�cations of this permit
OwnedLegal Representative Signature: Date: ��� � a' "� /
Oqeration Permit
Type (in accorclance with Table Va) ��
tem has been installed in compliance with applicable NoRh Carolina General Statutes, Laws and Rules for Sewage Treatrnerrt
, and all coad' ' ns of the Improvemer�t Permit and Constnichon Authorization, tswance of this permit implies no
$ sysbem stalled wiQ function properly for any given period of time.
� �I-a�-o�
Authorized State Aaent Date
PCHD, rev. 03l07/01
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. .. . ._ ___ ._.. . . _.. _.�. ___ _.._.._._. .... .. _. _.. _
P�rson C�unty Heaith. Departmeni
E�nvironmeratai Heaith Secfion
Si't'� S14E1'C�
Tax Map �: /� � ��
Parc�i #: �
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e Su d1 'sion Sec�an/Lot# - . /: ,` :. ,
Ap �i s Nam .
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. Autha Agent Date � �
,Syatrm con�nnert� represent apprwdutate car�toras otrly. TJ% canbwdor mrist� the systeat.
prror to � dis i��alla�n to insttr� ?hat pnvper �rada is nra�ai�ed
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Tax Map #: �D . Parcel #: 3�
Zoning: Township: F�u� � �t r
Subdivision: C�a Krid�c �Cres ��;�,: ,: .. Section: Lot: �os
Applicant: �Q I'1'� M�! IT4 ca I�i�S
Location• Nk�� �-
Operation Perm it
e
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 RIZATION. -
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� Authorized State Agent
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9�!L��� Sc� ,��'�C3�Ei3 ��L:4N �t�F� �IIEiL S1'i� l.��,�OL9?
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Tax 71AaP �:
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Zoning e. ... .
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Tvae of lNater Suat�iv:
Reauiremenis-
Well Permit
�/ Individua! Community Pubiic
Site Approved by �N I I- I-01
Grouting Approved by � S -� - ���
Welt Log �3 c+ i � -��
Weli Tag �[
Air Vent
Hose Bib
Concrete Slab
Well Dritler•
Well Approved By:
�- r,�.x., - � _. "___...., r ..
Date: ���" � i�- C71
**See Attached Site Sketch**
Wells must be 10. feet from property lines.
V.yells must be 100 feet from septic systems.
Wells must be �at least 25 feet from any buiiding foundation.
Other conditions: � �
PC}-ID, rev. 11/29/99
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date:�L/ � -d I
Owner.
Location/Directions:
Subdivision Name: _
Drilling Contractor: _
i
SR#
Lot #��,�
�
WELL CONSTRUCTION V
Distance from Nearest Property Line 1 v Distance from Source of
Pollution ( G �
Total.Dep.th: / D Ft. Yield: �' G M Static Water Level a2S' Ft.
Water Bearing Zones: Depth 1G��Ft. 2��t � F� Ft.
Casing: Depth: From 6 to /p0 .� Diameter: Inches
TYPE: Steel � Galvanized Steel
If S teel, does owner approve: Y�s No
� � Weight: Thickness:� '� Heighc�Above Ground: /`� Inches
Drive Shoe: Yes ✓ No .
Were Problems Encountered in Setting the Casing? Yes No �
Ir "yes" gir•e reason:
Grout: Type: Neat Sand/Cement / Concrete
Annular Space Width � Inches �
Water in Annular Space: Yes No
_ .. Method: Pumped - Pressure � Poured � - �
Depth: Fr�m � :o � O 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 INFORMATION IS CORRECT AND. THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTTH REG/,�LATIONS SET
FORTH BY�THE PERSON C^v'vi�ITY HEALTH DE�ARTMENT/�
►
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Signa re of Contra or Datc