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Persoe Cau�v Hesith Deoartmutt
Enviro�merttal Heatth 3ectlon
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IF THE INFORIIAATION IN THE APPUCATION FOR �AN IMPROVEi1�ENT PERMIT IS FALSIRF�. C�WNGED. OR THE SfTE !S
ALTEi��. THEN'THE 1MPROVElNIENT PERMIT AND AUTHORiZA'TION TO CONSTRUCT SHALL BECOME INVALID.
1) Ps�mlt roqwatad by: (owa.rlag�ntip�v. ownerj: �� ,n, �. ,� f�-n u� %;„s
�'iOfI1� �t10fl� _ <� G^ �'� `�.. _S h �, • � ���1, <'_� `,' a:�.r� 1 f w� � 6�S �'icl�
Bl�iR10� �1Of10: �ti ' � ��t.I�n� o
Z� Wam� and add�ss of c.urraat otwruc �� n.Y. T
3) Prop�rty D�scaiptio� Lot st� !. 1 c T� _�
Di�eciSons to it10 inadt� �[id n�unba�s v�. �-M r � n�
P��Y ��� � �.1' �_, � - k n .n _.��r
�
� P[apos�d Usa and Structutr Dacriptlar anawec cach afthe faDowinq quea�ona: .
� ProPaed Q�Gdst�nq �
b) Stldc Buit q Moduiar L'� Slnsle Wlde 0. Doubb Wid�e6�
� Nuttsbec ot 8sdtooma: .�, � Nutnher af oc�ac�Ls� ct peapta tc be sanrs� �
a) Ba�em� Yea Q No Q-If yea. � ot basemant fix4uex
' A GarbaQe Di� Yes q No �"
� qh�onsof Proposed Strv�u�a: WidttL ��,,,�K Dapttr��'
� w�' �++PPhI �YP� Privab q(new Q or eodatln9 �f. p� 4�I o. Sp�in� �.
Ars arry wa�s on adjoini�g propat�t Yes 0 No E&lf-ye:. locatiot�
6j PMas� Indicab Daii�ad Syst�m iP�= i� can be ranbd 1n o�drr ot youc Pnfi�ncs)
VCottv«ttloaal Yodifi�d Cornsntlonal _Albmattv� �movWw
Oftw� (sp�diyj:
CLEARLY. STAKE ALL t'ARNERS /WD L1NES OF?HE PROP9tTY.
c STAKE THE CORNERS OF ALl. PROP08ED 9TRUCTURES.
PtEASE ATTACt! SURVFf PU1T OR SRE PUW TO'THIS APPI1CATlON
I ha�'ebY meke ap�6r� to the Person Cautty liealth Departr��t ior a s�s evaluaUon tor the an-si�e sewaq� dhpa�► �
ths �bove�esaibed propaty. l aq[ea tl�at the contents af this appllcatlon a�s true and t+�ec�i the maodrnton � bo
pfecad on tl�e propecty. !� if 1he s�a ts alteced aths ��6erded us� c�pes. ths pem� sha�i bac�n� irnra�d-1 tx�ders�
ttt�t as ap�rt, I am c+espor�ie fac idantltj�ing and nm�iCin9 ProP��Y iiros. cane� anci maidng ths ai�e a�s �ac
parsannd Pe�son Cour�ly Hes�h Depa�cnatt to condu�d their evalt�allons.l ta�ecatand that 1 am t� �"Q�9
He�th it rtr�t anY v�etlands aa duiqna�ed bY the Acmy Co�ps of E�rs-
�'4� % � r °°
or t�ai Repc�t[ve . oate
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I�:�:�7���.n;�.���:.�.11 �-�C��.��::lh�
�181�t��F➢� Ad��tions/ l�o�ile �ome Re�l�c�a�a��nt�
Tax Map #:�_
Approval Requested for:
Parcel#: 3
Mobile Home Replacement
—� Building Addition
Applicant Name: �o��Cl �� C-� 0.y �01J
Address: � ct�-- -2
xbo�-o � c � �s �4
Phone #'s: 3�6 S'9�l — 3 7� � '
Permit Located: �/ Yes No
Installation Date: (— JQ — 03 Design flow: 3 0� (Dpd)
Current Contract with Certified Operator on file (if required):
Water Supply: �/ Well Public or Community
Wastewater system shows no visual evidence of failure on: ta —— D g (date)
(Applicant's signaiure if site visit is not required) W �'�_
Comments:
i>Lt�rl���n n �
A di�goa� pl�ac�men� �pp�roves�
�-�-a�
Envi onmental Health Specialist Date
11/15/OS
���, s� ��I�.� ��
�. -- � � ��� 1L
I-��a�aa-��.,.-,,.;, �aa��.Il. IE���.Il�I�n.
Applicant: �,�,r,� �,r�,��,��,t/�
Location: � �,,,��.���.�,,{� � ,
T��x M����� � r p�.rcel # �
S�uhcl!ivi�s�ion / . ! �� � ,^
Ph�•s�e Section Lot �
Improvement Permit
Permit Valid for Five Years _ No Ezpiration
Type of Facility: �,�u New �Addition Water Supply —��_
# of Occupants # of Bedrooms � Projected Daily Flow ��D g.p.d.
Proposed Wastewater System: �,,,/,/�„o„L,,Bi1�,,� . Type: � �
Proposed Repair: �,�,/f�q/�e,�� Type: � �
Permit Conditions: �cz�� �?���. � ,� �- �� �r o�.�>✓ .
Owner or Legal Representative Si ature: ' � Date:
Authorized State Agent: Date: �' • 7 0
� �S'�.-✓o�� %f�'a �
The issuance of this permit by the Health Deparhnent in oes not guarantee the issuance �of other permits. is the resp i ty e
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements aze met This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rules for Sewage Treatment and Disposal Systems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warrants that the septic tank system will continue to function satisfactonly in the future or that the water supply will remain
potable.
Authorization to Const�uct Wastewater System �Required for Building Permit)
* See site plan and additional attachments (_).
Proposed Wastewater System: �p,�/�{�✓�-�,`(
New � Repair E ansion _
Type of Facility: ��{
Type� Wastewater Flow .�a g.p.d.
Soil �TAR• • � g.p.d./ ft 2
Basement Yes ,/No
Wastewater System Requirements
Tank Size: Septic Tank: /p00 gal Pump Tank: "' gal Grease Trap: "" ga1
Drainfield: Tota1 Area: /�,00 sq ft 'd'otal Length �` O ft Mazimum Trench Depth _� in
Trench Width � ft Minimum Soil Cover: � in Minimum Trench Separation: 9 ft
Distribution:
Specifications:
1� Distribution Box Serial Distribution Pressure Manifold
Authorized State Agent: �
Permit Expiration Date:
�00
Date: �� (o p 3
��' ss�-��
The type of system permitted is X Conventional Innovative Alternative. I accept the specifications of
the permit.
Owner/Legal Representative:. � Date:
PCHD7/30/2002
Par9on C�uniy Mealth_ Department
� Er�vironmental Health Sec�ion T� �� *: . �i �
� � Parcal #:
S�'� S14E'tCi� ... . . __
_ .. __ � -_ � _.. " ili . O���E ,L��„� �Go>�7�
APPQ � s (�arne Subdivision/SecctioNLot# .,:: ;- . � :,
=7 � zc�v . .
. utho nt ��e � �
►gy�m c�mpone�tr nPras�nt oP�r�ouaimate cuatou�rs only. The ra�o� mrrsit,�lag the ayshae�
prior fo � die Lrstal�ioA to inrl�re tbatDrnPergrQde is maintaured
� �,,.� Q���-��s : 5q?-� � 7go .
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Scale: � ,�= So'
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� G/��S G'' /DO �
�T.¢-1�, = d. 3 9.�� �-z
/✓�: !-�•✓�s a�✓ Co.✓rav/�
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D_� �..�T�����.�
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Applicant:
Location:
,
T��x Ma�p �i P��rc�el �
S�ubd!i�vis�ion �- � �� �
/
'Ph�s�e Sec�t�i���� Lot �'
Operation Permit
System Type (In Accordance With Table Va): �. o
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AiVD DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZATION.
� ��1,����.� --- �-�o-��
Authorized State Agent Date
Installed By: ��,���-n S Date:_�/ -- l D� �,�
� �•
5�
N
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0
PCHD, rev. 07/29/02
�� �
S��'�'lC i�+NK 9PlSPE�TI�IV �tiE�B�CI..lSi' (i'ype il - Il���J �
Tax Map #,_ i� Parce! #_ �T System Type (Tabie Va) .��—
Owner/Appiicant ;'� Subdivision C��r, ��� �.ps
Address/Location Sec/Phase Lot # �,�
State ID/date5���-�
Capacity. `;6vo
Tee and Fiiter✓
Baffle ✓'
Sealant i
Riser (if appiicable) ,
Tank Outlet Seal .�
Permanent Marker ,
Pump Tan
.�
roof /Sealant
�
nncauon L�nes
Width ,� ft.
Depth � ��- in.
Lenqth r�,�ft.
Trench Grade .�
Trench Spacing �
Rocic Depth and Quali
�" Dams/Stepdowns etc.
Pressure Laterals
.. Hole Spacina
. Riser
Water Tight
Pump
Check Valve/Gate Valve
Anti-siphon o e
. . Floats/Switches � � ... . . �
Alarm visable and audible
Electrical Components
Rate (qpm)
Approved Pump Model
Blocic Under Pump
Pump Removal Rope/C
Distribution Sy:
Low Pressure Pipe �
Appr. Pipe Material and Grade -�
Sleeve
� Required Setbacks
From Welis �:
From Properly lines
Structures/Basements
Surface Waters -
Public Water Supplies
Vertical Cuts (>2 ft.)
Water Lines
Vehicle Trafftc
Easements/Right of Wa
Other
o �' Easements Recorded
Tri-Partate
Comments�
/
(
pchd rev. 3/13/01
P��S�R! C�lH6V'i`f ���l�R�NMIE�ITi�L HE:�►LT�3
p�,�,,�� S�� �A�':4C}�Ei� 4'�N F�t� '�VUEi� SiT�E L4�lOU?
T��� � � � P�� � 3� 9 � �
T�P �-� .� Y�. ,: :,
Zoning _,,,_,_ _ _ — . .. _ . . - . . .... .
1 i • //
Lucatt0�
� � ��_
� � .
Well Permit r
Tvae of Water Sua�iv: ✓Individual _ Community Public
Reauirements•
Site Approved by C ��- � -, �� -�
Grouting Approved byC'�S 1-1�- °3
' Weil Log � � l - l �l-03
Well Tag C�� �� i 5-�'3
Air Vent C-5� �-� S' �3
Hose Bib C"� S_�- � 5-�3
' Concrete Stab � 1-� s-J3
Weli Dritler: . �Z�� W �� ��
Well Approved By: �
�
Date• I - I 5 � �
**See Attached Site Sketch**
Wells must be 10. feet from property lines.
V.yells must be 100 feet from septic systems.
Weils must be �at least 25 feet from any buiiding foundation.
Other conditions: � �
PC}-10, rev.11/29I99
���� ��
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I���a-o������.11 IE���.Il¢I�n.
Owner: 5�•� ��
r.o�tion: a�, ��c,
Subdivision:
G
C
�ao� �o� y
o , � ,��,�,� � � 1���/ ..��.
�� �-��—a�
GroutLog
��r
Tax Map ��/� Parcel # �
SSG�S �-��.1 I
LOt # ��
Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from Septic System (Minimum 60 feet)
Total Depth: /�1U ft Yield: �3 GPM Static Water Level: _� ft
Water Bearing Zones: Depth 7S ft J�,�� ft ft
Casing:
Depth: From _�� to � ft. Diameter: %�� in
Type: Galvanized Steel �
Weight- Thickness: .� Height above Ground: �_� in
Drive Shoe: • Yes No Any problems encountered while setting casing? Yes
If "yes" give reason:
No
Grout:
Neat: SandlCement � Concrete GraveUCement
Annular Space Width inches Water in Annular Space Yes x No
Method of Grout: Pumped Pressure Poured � Depth to
Materials Used:
No. Bags Portland cement �� � Weight of 1 Bag � Pounds
If mixture (sand, gravel, cu ' gs - Ratio to
ID plates: I,�Yes _ No 4 x 4 slab _ Yes _ No
Drilling Log Location Drawing
From To Formation
D v�-� '� ��
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N
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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 Dep ent.
Signature of Contractor �C/ ID# O,2 �/ Date �-�,� �4�
PCHD rev O1/16/02