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Tax Mao �k y4- '�t a
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IF THE INFORMATION IN THE APPUCATION FOR �AN IMPftOVEi11ENT PERMIT IS FAL31Fi�. CHANGE� OR THE SiTE fS
ALTERED iHEi�l'T1�lE 1MPROVEIUIEid'T PERMIT AND AUTHORRATTON TO CONSTRUCT SHALL BECOME INVALID
�) P.�t ��a by: �own.�e.���. ��: ��� �.., �, ,a u�,.,k� ,��
' t'IOli1a Pt10fl� .�1� �-I -��S 6 2 • Ad� ��l .� l�r, r 1%r s�n' F k l��J�
8tniness Phone: �� ' r-�7-,rhnr�,
Zj tram� aru! address of currsrtt ovrMr. � ca ,�, Y_
3� Prap�rty D�scriptio� Lots� �, aoTar�t�pc �
D�edtons ta the p�opecty ��1 r�d ttia/m�ea actid ntunbetak
(/ 1•,l 1 t'�r nt I!� /, i, r.i
4) PtaQos�d Us� and Strucatra D�scrlption: anawa each of tha �owicW que�o�m:
� ��� �� 0
b) Stldc Buit 0. Moduiac 0. S�qk Wlde 0. Dari�le Wida �
cj Nun�bar a� Bedroocnx �, � Number at acapants� a� paopl� to be sacv� y
�) Ba� Yes Q No �fyea. � ot basett�ent fGducax
' t� GarbaQe Dtsposa� Y�s 0. No f�
� Q�ionsat Pto�osed S�x�u[a V4id@L � R Daptr � a
��� �PPhI �= P�iva�s q(r�ew a ar eod�lnp W. Puhwc 4 Cou�rna�jl 4 Sp�in� �.
Are any weqs on adjoi�ing pcope�ty/? Yes 0 No C�If yes� loc�lton
6j PM�s� Indicab Daiisd SYsLam 'iyp�: (systema can bs ra��lo�d 1n ordK of Y� P��l
�Ccmrentlonal Modified Coav�rttloaal _ /►tb�ttvr �w
OttMc (sp�diyj:
CLEARLY 3TAKE ALL CCRNER9 AND t1NES OF THE PROP9tTY.
3TAKE THE CORNERS OF ALL PR,OP08ED STRUCTURES.
PLEASE ATTACtI SURVEY PU1T OR SiTE PI.OW TO THIS APPUCAT[ON
I he�abY �k�e a�B� to tha Pecson Cattrty Health Dapsrtriwd ioc a a�s eval�lon ior the on-ai0e aawaq� disp�l syst�m
ths above�ibed propeciy. l ag�e that the coNents of thb apQYcafton ars true and t��i the ma�amucn � tu
ptacad on the proQecty. 1�u�derstand ifths s�a is aite�ed orths ��tmded tw ct�Ctpas� the pertn� �a�Y bemms irnra�d. i wzdarst�
tt�t as ap�BCarrt„ 1 am twpons�ie fa idauitying and marbn9 P�'�Y iines, comers ard maidng ths ai�e a�s �oC
pacaonnd of Person Ccut�ly Hea�h DepatC�nerrt to condud tt�ir avaltsatlons. l ta�atand its�t i am t� �' �9
H�Ith D if my propecty,��x� any v�etlanda aa dai�ed by the AcmY Co�ps oi Erpi�s-
v/ r 9 a� �'— 6t�
ot L�al Rapc�Native , Oabe
Aocitcadon Date: t - C�-da.
Amount �aid: �125 -�
Reca�,#�
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Tax Map #• A c'J �-1 �
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i�arcal �: 3�
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�IF THE INFaRMAT1aN IN THE APPl:1CATtON F�R AN INIPRO�EN'T P�11AIT iS INC�RRE�'T'. FALSiF�E�J�
. C�FFANGED. �3R THE SITE IS ALTERED. THEAI THE IMPR01/E3UIEi�IT PERAAR AND AUTHORiZAi10N TO .
CON9TRUCT SHALL BECOII� INVALlD. •
1) Pemtit rscN� hY� (�B�B�P�A�e ovvner):��+os i�i=�
Home Phone: � SZB-�'7�g Address: � 1 .
Husiness Pl�one: 1 L-u-�t �
2) i�iams and �ddress cf current ovmer;
�
. �
3� Ptnperty Descripti�n: Lot size: Tawnshl�: Subd'niisian: �.tc,��. Acr�s Lat# ?n �
Diredions to the prapert�/ (Induding road names�and numbers): •�
4) proposed Use and Structur�s [�criptlon: answer eacii of the fioltrn+vtng questions:
a) Proposed _, Existin9 �TYPe of Struc�re: , i c'�- 1Mdth: ' De�th:
b) Number af Bedrooms: � Num6er of �� or people ta be served: -
c) Basement Yes , No WW there be piumbing in the•basement?
d) 6arbage Dispasal: Yes Na — -
� w�' �PP�7F Tll�: Private _(new � ac exlsttng j� Pubiic� Commw�y� , Sp�ing � .
Are any welis on adjoinin9 property? Yes Ido _ If yes, ple�ase indlcate apavximate locatiari an the
•site pian. •
� Daes your props�ty corrtain_p�viously ideM�ied jurisdic�lonal w�tands� Yes No
Pt..EASE NOTE THE FOLLOWING:
➢ A Pl.AT OF THE PROPEiZTY OR S17'E PLAN MUST HE SUBMITTE� WRN '9'HIS �UCATION.
➢ PROPEi�TY UNES :4ND CORNERS MUST 8E CLEARLY MARKED. •,
9 THE PROPOSED LOC�4T10N OF ALL 9TRUCTURES MUST 8E STAKED OR FLAGGEi�.
D THE 31TE NIUST BE RE�DILY A�CESSIBL� F�R AN EVALUAT]ON BY THE HEA►I.TH DEPA�RTMF�1'i'
S'I'AEF. .
I here�y maice applic�tian ta the Person Courrty Health De�artment fw a siie evaluatlon for the on-siie sewage disposal
system for the abave-descrihed proQerty. 1 agree that the cor�tents af this applicatfan are true and represertt the m�cimum
faciiiiies to be placed on the proQerty. 1 understand ifi the site is attered or the ir�tended use ct�anges, the pefm� shaU
became irnaiid •
Cwner or Legal Re�resrantative �
Qate
PCi-ID, rev. OBl'L7/02
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Applicant:
i�'t�-i: >
T��x M�� � � F�rc�el # _�,� •
, �,
S��nc�l'ivi�s•ioi� . • �
i�
Ph���s�e Sec�t�ion Lot # �
�, � • �. � � rt ��.. �
''`' - , � Improvement Permit ,
Permit Valid for Five Years No Ezpiration �
Type of Facility: � � Nev�N Addition Water Supply ��
�
# of Occupants q # of Bedrooms � Projected Daily Flow � g.p.d.
Proposed Wastewater System: C011,V ��� " Type: �1 �
Proposed Repair: �{/ ' _ - �' Type: ��
Perr�it Conditions; �p � Vl �✓i a. d���-i C�y�'� q- f- l`Q9t�T �p d� cl�t�✓�i'�- uu�l�S � L� r
Owner or Legal Representati
Authorized State Agent:
Date:
Date: � —D
The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation If the site plan, plat or the intended use changes. The Lnprovement Permit is not affected
by a.change in ownership of the property. Thls permit was issued in compliance with the provisions of the North Carolina `Laws and
Ru[es for Sewage Treatment and Disposal Systems' (15A NCAC 18A .1900).
�� � Authorization to Construct Wastewater System �Required for Building Permit)
* See site plan and additional attachments (_).
Propose�astewater System: Cpl� V. Type � Wastewater Flow 3�d,�.p.d.
New �� Repair Expansion _ 5oi1 LTAR: •�� g. .d./ ft 2 ,
Type of Facility: ����5-=-= ' . Basement _ Yes �io � _
Wastewater System Requirements
Tank Size: Septic Tank: ����al Pump Tank: gal Grease Trap: gal
Total Area:1QCCL sq ft Total Length �C� ft Maximum Trench Depth �� in"
Minimum Soil Cover: � in Minimum Trench Separation: _� ft
Distribution: Distribution Box ✓ Serial Distribution Pressure Manifold
Specifications:
Authorized State Agent:
Permit ExX
The type of system permitted is
the pernut.
Owner/Legal Representative:
Date:
r� ,�� �ur u/� ��52.� b� �S� l�'
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Date: � ��`� �
.
Conventional Innovative Alternative. I accept the specifications of
Date:
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Name ��s 1�: N� , Tax Map #�1 �!o .Parcel # 3s�
Subdivision dak.n�+c-� ��s � Section/Lot# 'i �
� 11 - Co--va
Authoriz State Agent � Date
System components represent approximate�contours only. The contractor~must, flag the system prior to
beginning the installation to insure thatpropergrade rs mcrintained
S�
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PGHD, rev. 09J12/Ol
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SITE SKETCI-� ��
Tax Ma.p #�..Pa:rcel #_�
Section/Lot#_ �o
2`�' � �
Date
System components represent approximate�contours only. The contractor must, flccg the system j�rior to
beginning the installation to insure thatpro�liergrade is rriaintained
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Zoning:
S�bdlvision:
p�e� #. ��r
Touvnship: ' �
' . .3ectlon• � Lot j �
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Appii�ant: r ,
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Location• �
:; .
O eration�Permit � .
. . System Type (in Ac�ordance V11'�ttt Table Va): � �
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STAi'UTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL, '
AND ALL CONDITIONS OF THE IMPROVEMEiVT PERMIT AND CONSTRUCTiON
AUT�IORIZATt .
CL �a�- � 2-�~�� � .
orized State Agent Date .
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PE�SON C�UNT`� E�A/iRONME�iTA►L IiEAL' TH
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� Weil Psrmi# ' '
Tvae of Wat�er Suoptv: ���� ���Y • Pubfic
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Reauir+emen�s•
site APProved bY �� 2-1 ��2 �
Groufmg Ap,P - �- 0 �
Wefl Lag J ' t
Wel1 T �
Air Vent ✓ ' 2 .
Hose 8b '
Concr�e S1ab _
wan o�te� 1� v�-� �� � �
Weil Approved By ;/�(�,y� l�� ��! i��� -.
0
n�: 2 � �I —�Z
*'See /�tEached SHoe Sia�bcis"
� V1►eits must be 10 feet from proQeti�/ �i�►es.
Wells musf be 100 feet from septic systems.
WeUs must be at feast 25 iset from arry buiiding foundation.
Other cond'r�ons: .
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PCtiO, tav. 1 VZ9/9g
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WELL PE�tMIT
PI.�4SE SEE A'�1"I'ACHED I'I.AN FOR WELL SITE L.A3�OU'�
Tax Map #: �► � Pazce1 # 3S$ Township
Applicant
Subdivisioni �� c�c s„� i�c/'es Section: Lot ��
�cation: � ��f' i2Z � �cc�''.�v'ca.�c. � �� �Sc.��S Ir�•' �
i� �S o.c.� �s 1� ..1
'Y' e of Water Su 1. � dividual Communitp Public
Itequirements•
Site Approved bp � � ��a
Grouting Aggtoved bp � ��
Well Log �l
Well T
.Air Vent
Hose Bib
Concrete Slab
Well Driller. �on,e N2 �►V� 1(��-•11,
�
Well Approved �y: Date:
'�°5ee Attached Site Sketch'�`
Wells must be 10 feet from propertp lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from anp building foundation.
Other conditions: � i��..J S� ke S� �-c�.
PC�ID, rev 09/07/Ol
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Drillller ID # I
Compa,ny N�,me
D�t�e Dril!Ied
Well Log
p��; �� �y� Tax Map�_ Parcel # �.,5g
Location: �
Subdivision: � r � Lot # 70
Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from Septic System (Minimum 60 feet)
Total Depth: ���'/'� ft Yield: � GPM Static Water Level: _
Water Bearing on�es�. Depth�'��c�j ft� ft� ;.'ft ft
�
Casing:
Depth: From _� to ��_ ft. Diameter: � in
Type: Galvanized Steel t/
Weight: Thicl�ess: . I� � Height above Ground: _� in
Drive Shoe: Yes No Any problems encountered while setting casing? Yes No
If "yes" give reason:
Grout:
Neat: Sand/Cement _ j„� Concrete GraveUCement
Annular Space Width inches Water in Annular Space Yes No
Method of Graut: Pumped Pressure Poured Depth to Ft�
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
(iG r -r 1- �
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I hereby certify that the above information is cotrect and that this well was constructed in accordance with regulations
set forth by the Person County Health Deparhnent.
Signature of Contractor ID# 'i?� ��� Date r./� -�-�
• PG`�iD rev O1/16/02
���,5� ���� �� ��ca�' �D � 3���/ ,�
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���������.��.� ���.Il�� D�o �B�l i l� 7•0 �-
Owner: �u,�►-r<
Location: �
Subdivision: /� G:
��out Lag
;
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C S LOt #
Tax Map ,� �%j]
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Parcel # �
Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from Septic System (Minimum 60 feet)
Total Depth: .�2U ft Yield: �� GPM Static Water Level: 2� ft
Water Bearing Zones: DepthZGr ,jft ft ft ft
Casing:
Depth: From (, to � ft. Diameter: >'� in
Type: Galvanized Steel �
Weight: Thicl�ess: �%��' Height above Ground: /� in
Drive Shoe: Yes No Any problems encountered while setting casing? Yes � No
If "yes" give reason:
Grout:
Neat• Sand/Cement _j� Concrete GraveUCement
Annular Space Widt� inches Water in Annular Space Yes No
Method of Grout: Pumped Pressure Poured � Depth to
Materials Used:
No. Bags Portland cement �� � Weight of 1 Bag SD Pounds .
If mixture (sand, gravel, cuttings) — Rano to
ID plates: �Yes No 4 x 4 slab �Yes _ No
Drilling Log Location Drawing
Ft.
From To Formation r�
7 g ' �- �� ' ��I��.
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I hereby certify that the above information is correct and that this well was constructed in accordance with regulations
set forth by the Person County Health Departme t.
Signature of Contractor � � (� :-' ID # _s C 2C Date %f - � v �