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1� THE INFORMATION IN THE APPUCATION FOR �AN IMPROVE�AENT PERMIT 13 FAL91Fl�. C�WNGED OR THE S1TE !S
ALTER�. THEN'THE 1MPROVE�4AENT PERMIT ANO AUTHORRATION TO CONSTRUCT SHALL BECOME INVALID �'�
1) Plcmit requ�abed by: (Ownulag�ntlprospactiw awne�: �� n, �_a �1,� ti�k r.� t
Hotns Phon� ���-� - a.� i 2 � A�d�as S�-I � S�t' W�, ��l l• rn � A t �4c1,
Bt�sil0aa pil0�e: �� /Z c9-X hnr n
�:�i�iii� ifld i�[�i O� C�lRtii[t OW�fAf: ��/1 m Y
3) Ptoputy O�scriptlo� l.ot alx� 1. oo Tcw�t,� �.1.`� y�
Di�oro ta the propecty p,rx�kp road ilaci�as and ruunbe�s� � s n n,� c!/��. : l �
4) Pmpos�d Ua� and Strucxttr� Descriptlaa: anawet esdt at the fo0awi�W qu�b�u:
� Proi�oaed �d�q I]
b) Stldc Bu� Q Moduiar q Sinqle Wtde Q Doubb Wide (d�
d Numt�er at 8odtoamx �. � NtuN� of oc�upaN� ac peopl� to be serva� �
a� Basem� Yea q No �j�es. � ct t�aemec�t fixtiucex
' A Ga�e � Y�s q No �
�I 4�onsof Propose�i Strsx�ur�a: VVidtt�: � Daplr �
aI �� �PP�Y �� Prtv�te q(naw 0 oc eodsW�9 �� Qublic 4 Cocm�a�Y 0. Sprin� D.
Ars nny we�s an a�oi�ig pcape�t�? Yes 0 No C�Yttya, location
6j PMas� Indicai� D�sii�d SYaiam 'ijlP�= (aya�a cact be r��lo�d in c� of Y�' P�)
✓�onv�ntlonal Modtfted Cottvsntlorsal _ Atbrts� �nnovatlw
Ott�c (�[yj:
CLEARLY STAKE Al.l. CDRliER9 AND L1NES OF THE PROPER7Y.
STAKE THE CORNERS OF ALL M�OPOSED STRUG'iURES.
PLEASE ATTACH SURVEY PU1T OR SITE PUW TO'THIS APPLiCATION
I herobY maks a�6�a�On to trie Pe�on Cou�y Health Dapa� �Qw� a m'Es ev�aUon tor ths a}siis sewaq� disPosal syst�n
ttw above�isaaibed propaly. t� ttmt U�te caRGents cf this aQpl�ion ats tn�s and te�sent the mmo�rtn�n iac�tteu bo
ptsced on the ptvQecty. ! unde�tat�d iflhe s�e is alt�ced arthe i�rtandad tw cri�. the pertnit �aY beaonts unre�d. l unde�st�
thact as ap� I am tespor�ie for idau[fying and ma�idn9 P�Y iinea. canecs atd m�aidng U�e aiGe a�e Ua�
pecsonnel af Person CauMy Heallh Department io wndu�ct tt�ir avakmtions. I ia�nd that 1 am �° ��Y+n9
Heaah D tt m�f P�'oP�Y �Y �s as dai�na�ed bIl ��m1f ��Ps a 6�S-
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Application Date: G � `� � �
Amount Paid:
Receipt #:
Improvement Permit (Site Evaluation)
$200.00/$300.00 if> 600 �d
Mobile Iiome Replacement or Building
$150.00 (if site visit required)
Well Permit (New/Replacement/Repair)
$3 00.00/$200.00/$75.00
���.5 f ������ Tax Map: �6,.
. Parcel#: - 3 J C�
�. � ����'
]E��s��,,..,.,,���.Il ]FiC��.Il�
for Services
Services
Coastruction Authorization
(Fee is de endent on the e of
Addition Permit Revisiun
$75.00
� Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Informatio�:
Name: �� n o��+, �' �/�e y/
Address: / 3(o T. s�n � T/,
��x.ho�� , �c c�7,575�
2) Name and address of current owner (if different than applicant):
Name:
Address:
3) Property Description: Lot Size: �,qc�1e Subdivision:
Address and/or d'uections to Property: I�
O yes [�1"no
❑ yes �9
O yes �o
❑ yes �o
❑ yes L�t'no
�
Phone (home): "
(work/cell): 33CP- �} - (
Phone:
Lot #: �
„� .. ,_ ,.
t
Does the site contain any jurisdictional wetlands?
Does the site contain any existing wastewater systems?
Is any wastewater going to be generated on the site other than domestic sewage?
Is the site subject to approval by any other public agency?
Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
/� 1
4) Proposed Use and Type of Structure:
�esidential �
❑ New Single Family Residence Maximum number of bedtooms:
❑ Expansion of Existing System If expansion: Current number of bedro9ms: �
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes Q no With plumbing fixtures? � yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Squaze footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well L�7'�xisting Well ❑ Community Well � Public Water � Spring
Are there any existing wells, springs, or existing waterlines on this property? O yes 0 no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
❑ Conventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ qnY
I cert� that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, or if the �te is subsequently altered, or the intended use changes, all permits and approvals shall be invalid.
Sign�ture (Owner/ Legal Re�ese�
* Supporting documentation required.
(o �`i�iS
Date
Permits are valid for either 60 months or are non-expiring when accompanied by an approved piat.
A completed °Lot Preparation' form must accompany any application requiring a site evaluation.
��n�� �1 pPYCAI'1 �Altn+c! Lin�rir�mm�n+n� unn�4% 'i�i� C �/in.�rtnr. Ct C,.:4.. (� Il � �'.-. �___' '-
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_. - � P�E#�SaN Gt3llNTY E�iV1RONME�ITAL MEALT�-i
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Tix �lap 3: �`f `CO P�ned� � �}P
_ • 1_ •
zoniu9 Taw�uhlp Pt� • Vei�
� npQuanC �Ocr►'�my Ac,y�-tv.5
t.onBon:
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9uhdlviaicn: '__� (�G�� � � IA�lo2S
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� improvemen# Perinit � ,
� A 6uildin4 aermit can�ot 6e issued with anlv an Imarovemerrt Psnnit
New o��Repair Add�tort Type af S4udurs �� 1Nater Supply �� �� .
# of Oax�panb #of Bedrooms � Other
Hase:ctetrt? �Z 9asement Fndtues? .
P�l� �Y �'�e u 9.p.d pecmd VaUd Fcc: L�E a Y�rs ❑ No Expira!!on
Proposed wastewater System Typ�- _�,�✓���'7'0��
Pump Requiced?' Yes �No �, .
Proposed Repair •_ � � r� vc�� .,--- �
P�t c�a�:� �� � ,._. � �-'�,� 6�,..7�11�.., ..-� �.. o�4-tY�n u�,.:
, . / /�/ , � � . .
�l�l e S.�ta S�ia �� ct � r YL /JPr Q �QC�P —Fv �lCWi n{ �,m, [0 u I'• •
Owner or Legal Rep�tive S�re: p�;
Autho� Staba Ager� � DaEe: � — �o� `U %
The issuance �cf thia pertnit 6y the H�tth De in no way gttarart�ees !he lssuence of other p�s. The pemu't
hetder is respansihle for che�cing wiih appropriate govern�tg bodtas i� mee�rtg thelr �b. This sita ts
subject to cevoc�tion tf the site Plan, Plat. or the icrt��dad tt�e cl�angoa. The ImQroveme�rt Pemiit sE�all not be
affected by a change in owne�shlp ef the site. This permiE Ia subject to compliance vdth the provisio� of the
Laws and Ruies far Sewage Tc+eatrnent and Disposa! Systsms af tlte No�ttt Carolina Admini�trativa Coda.
�uthorization To Construct Wastewater Svstem (Revuired for Buiiding Permitl
Typa of 11Vastewater Sysbem ��D%vPic� / c r�,� Wasfewatet Fi�+u: _��.p.d.
Fac�ity TyPa; �►-. s fc( e� I r� Ntewe�Repei� OExpansion 0 . .
Basemenl? Q Yes o 8asetnent F6ctiuea? 0 Yea�'�to .
Waata�vater Svatem Reoninecnet�b ' ' - . •
. Sep�c TaNc Size: 00 ga{lons Pump T�k Size: _/`�( � gaQans
Tetal Tnenct� Length: �finet Max�rwm Trench Deptk Z-� �� Aggragale Depft�L in.
Maximum Saii Caver: ,� indus Tr�e�dt Separation: � Feet on Canter
. �.
Ot�er: .
Pecmit Expi�alion Data• � '- �a ` � .
Author¢ed State Age[� p�p; ``� `� 2� .
Tha type of sysbam permittad � doe9 C! net. diRer tcom the type specifled on the application. i accapt
tt�a specificabtar�s of tttis peaaIt ,
OwneriLegal Repre�ar�8ve Signature: p�;
PC}-ID, rev.11/18199
. . __,—._ _.. .. .--�-�--.__._...___ --- �
��r��n �aunty 3�eaitla, flepart�ne�rt
. . . �za�rironmeniaa Health �eciio� ��c��aQ �: �p .
� _ . . � � P�rcai #: Co � G
� Si� Si4�'rCt� � _ . . _.
.. _ ...r�?„ � -���;►'�5 � Kvi crt�s Lo� ��.
�`�'��1 —
Appilcarrt's Name S ivisioN dioNLct#
. Autho�ed S'tate Agent �a�e . .
sy� ���� �P�� �PP� c�atow� onl}. Tha ca�rtracsor mrr�t, flag tha sy.sirat
pr�iir to b��g !be �aUardon ia uura�e th� prnPar �ra� is � �-'
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SITE SKETCH
N e�a�� � ��1��� Tax Map #� y c7 Parcel #���
S �on �c+ Ac�s Section/Lot# �g
�� 3 i -O I
Authorized Staxe.Agent � Date
System components represent approximate�contours only. The contractor must, flag the system prior to
beginning the installation to insure thatpr+oj�ergrade is maintained
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PGHD, rev. 09/12/Ol
` PEi�SON COUNTY Ei�IViRONMEi�ITA+L HEALTH
PL�,4SE SE� ATiACNED PtAN FQR WE�L SiTE i..AYOUT
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Tvae of Water SuQalv:
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Reauie�emen�s: .
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tnd'nriduai Communifll. Public
_ Site Approved by � ��- � Z- Z-o►
Groufing Ap roved by_ 3 -z� -�t
Well Log i Z-2'1-� �
Weq T � �+ r z- '-o .
Air Vent s � 12-. -o�
I�OSe 81b 3' t-31-o�
C011Cl�� S43b 3 N 1 Z-31-o �
Weil Drilfe� 'd
Wel[ Approved- By:
�
n�: 1a-3i -a �
'*See ktiached Site SiaaficN'*
� Welis must be 10 feet from propeEty lines.
Wells must be 'i 00 feet from septic systems.
Weils must be at feast 25 feet from arry build'mg foundation.
Other conditians: .
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R � PCHO, rev. f'l/29/99
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PERSON COUNTY ENVIRONMENTAL HEALTN
WELL LOG
Date: � 2- 2
Owner: �AM��\ ��U��h-r��� � SR# ' � �
Location/Directions: � � �
Subdivision �Name: �-,; o-,�m--, � � Lot # C� _
Drilling Contractor: � , nc
WELL CONSTRUCTION
Distance from Nearest Properry Line ! c1 Distance from Source of
Pollution ( a a
Total.Dep.th: 12d Ft. Yield: GPM Static Water Level a.S-' Ft.
Water Bearing Zones: Depth �� ro Ft. F� F� Ft.
Casing: Depth: From 6 to�_Ft. Diameter: Inches
TYPE: Steel - Galvanized Steel
If Steel, does owner approve: Yes No
Weight: Thickness:� '� Height�Atiove Ground: I� Inches
Drive Shoe: Yes ✓ No _
Were Problems Encountered in Setting the Gasing? Yes No �
If "yes" give reason:
Grout: Type: Neat Sand/Cement / Coricrete
Annular Space Width � Inches
Water in Aruiular Space: Yes No
_ . Method: Pumped - Pressure � Poureti � - �
Depth: From O to � O Ft.
Materials Used: No. Bags Portland Cement Weight of .1 bag lbs.
If mixtuie (sand, gravel; cuttings) - Ratio: � to
ID Plates: Yes � No � � �
� 4 x 4 slab Yes � No
T HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTTH REGULATIONS SET
FORTH BY�THE PERSON C^v`vi�TY HEALTH DEPARTMENT.
gnature of Contractor /r ` Dat�
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