A40 360�-a �-06
Aoolicatio� Dato: �,�,
a
Amount P�id: � ! �'Q , b D
�i��
s
�� 303 6
� � �
1��D �,�
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,�i 2 `"
W
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�l � r 1 .�_LI� � HI •
_' + , ( • =� ' ' ,�►,� �2x
Pot+esl #; � � -� # 'i�,
IF THE INFORilAAT10N IN THE APPI1CATtON FOR �AN IMPROVE�AENT PERMIT IS FAL91REfl. CHANGED OR THE SiTE !S
AI.TERED, THEN'THE IMPROVE3111E�IT PERMIT AND AUTHORiZAT10N TO CONSTRUCT SHALL BECOME INVALlD.
1) P�rmit nqwsted "7• lOvmtd�goiitlprosporS. :� ownerj: �Cd M m U F.J12 s+.l� : nt,
' �'�Ofi10 �t10flQ. � �� �l -.�,�'SG 2 • � . L! �.`"�' .-ilr ril} t� s �,1.
81�1�5 �IOt�a: �� � rr^f 1, nr e�
2� Nam� altd add�es+s ot currant Ovrner: ���• r.�. x
3) Prop��ty D�scr�ptioc� Lot � I. 6a Tar� �i'`�_
D�rac�ons to the P+'�P�Y (��+�W � names arrd luud
4) Pcapos�d lJa� and Struc.tuc� Daariptlacr. answet ascl� af the fodawi�W que�iona:
�1 �P�� 0.�� Q
bj Stldc 8uit q Moduiar 0. Stnple Wkie Q Darbie YWd�e �
c) Numbe� af 8adtoornx �. � Number ot oaupants a� paopia to be satvac� �-i
e) Baaeme�C Yaa q No I9�yes. # of bassrt��t ttxbtuex
'� GacbaQe Oisposa� Y�s �. No 19''
�? 4�ions af Pnopo�ed Stirtx�tue: Yllidtt�: aN Dapdr �
al ��+PPhf �YP�- Pdvats q(new � cr mdstin0 �q. P� 4�Y 4��W �.
A�a any weqs oa adjoining pnpat�/t Yes � No �-lf ya. bcaflon
6j PMasf Indicab Oaii+�d SYsiam 'lyp�: (sysmms can be r�nio�d 1n o�d�sr ot Y� P�'�)
� .�'"omtentio��al Mo�d Canv�etta�al _ A�ivr �
Oftw (s�:
CL�ARLY STAKE Iu.L CDRNERs AND LWES OF THE PltOP�TY.
STAKE THE CORNERS OF ALl. Pi�OPOSED STRUCTURES.
P�EA�SE ATTACtI SURVEY PUIT OR SRE PLAN TO TiitS APPUCATION
I he�'ebY m�a a�6�ti� to the Pe�ar► County Fkalth DaQa�tr�ar�t ior a s�s evaluatlon for ths on-sibQ sswaqa disPosal syst�m
th� sbove�escr�ed propecty. t agros that the cos�tenb of this appiiqtlon acs tn�s and rop�a�t the �� bo
pfacad on the pcopecty. 1 unde�tand if ths s�e ts ait�ered aths inbended ttu ct�at�pas� tha pemdt s� becoms invafird- I tx�dec�t�
fh�t as app8cant, I am cespor�a�ble fa id�ing and merfan9 P�'oP�Y iiros, caners and maidng ths si6e a�1e �o�C
pecsonnel Person Courtty HeaMt► Da�par�mettt io canduct ttrair avakmflons. I tardo�atand that 1 am r� ��9
Heslth D i# my any wetlands as dai�hed by the %4n�f Corps of 6�i�s-
�%wo��,'�lir►� %r �2 � — � '
or t.aqal Repceaas�tative pa�e
Aaalication� Date: [� � . . . Tax Maa:�
Amourtt Paid: � - � . . - r .
Recaiat#': .. ��� . . Parcai'#:
' ��� �• �� _ ���� �� .
. . � ���1.���
� • . ����.e���.,r..e���.7E IF���..71:�
� APPUCATION FOR 3ERVIC�S
1) Permit rsquested by: (�wne�lagent/pror�pective owner): D�-lG� �
Home Phone: Address: � �
Business Phone: �i7 �d�/ � �7�3
: ^ �,
2} Name and address of current owner: _�
� �
3) Property Descdption: Lot size: i� �' Township: _�� Subdivisian: �
Directions to thg !rolerty (Including ro riiames and numbers): �.
� : l� � ,` �,n rst�-�/ ��► _
4) Proposed Use an -Structure Descriptlon: answer each�e f�ilowing ques�ons:. //
a) Proposed _, Existing Type of S�ruclure: ;� / w Width: ��' Depth: 7"�
b) Number of Bedrooms: l`�+ Numbe�r of occupants or pebple to be served: _� ..
� c) Basement Yes _, No dl there �e mbing in the basement?
d) Garbage Dispasat Yes _, Na _ . �
� 5) Water Supply Type: Prn+ate _(new _ nr existing �, Pu '_, Community � Spring _
Are any weils on adjoining property? '✓es _ No yes, piease i�dicate approximate locatton an the site plan.
6) Does the property contatn previously id�enttiied jurtsdicttonal wetlands4 Yes _ No ✓
PLEASE NOTE THE FOLLOWING: � � .
�➢ A PLAT OF THE PROPERTY OR SITE �LAN MUST BE SUBMITTED WITH THIS APPUCATlON. �
➢ PROPERTY LINES AND CORNERS MU�T BE CLEARLY MARI�U.
➢ THE PROPOSED LOCATIOPI OF ALL SiRUCTURES MUST BE STAitED OR FLAGGED. �
➢ THE SITE MUST BE READILY ACCESS�BLE FaR AN EVALUATION BY THE HEALTH DEPARTiNENT STAFF.
I� hereby make application e Person Co�nty Health Department fnc a site evaluation for the on-site sewage disposal
system for the above-de rib e I a�ree that contents� of this applica�on are true and repceserit the maximum
fiaciii�es to be placed the rope I unc�erstand ' the site is aitefed ar the intended use c ang the peRnit shail
become invalid. � �Z�
Owner or Lega eprese�tati�ve ' � Date
- Pct�w, rev. �on7io�
e
:.
PERSON COUNTY EiVVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN F�R SOIL AREA AND SYSTEM LAYOUT
Tax Map #: � � Parcel #. 3 6 0� Township �L�'T � 1��_ PIN
Appiican�
L.ocatlon:
New ✓ Addition
# of Occupants
Projected Daily Flow: �
Proposed Wastewater
subdiWston ���L �� w�asersecuoa �, �otlF�Z_
.,--.
Improvement Permit
Type of Structu Water Supply Wf�C..1_
� rooms Other System Type .�
_ Permit Valid For. ive Years ❑ No Expiration
Proposed Repair. [�2n/✓.
Permit Conditions: �� � �� ��i�i i�i � N
Owner or Legal Representative
Authorized State
�
The issuance of this permit by the Health Dep�Nfient in no way guarantees the issuance of other permits. The pertnit 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 intended use changes. The Improvemerrt Permit shall not be af%cted by a change in ownership
of the site. This permit is subject to compliance with the provisions of the Laws and Rules for Sewage Treatment and
Disposal Systems of the North Carolina Administrative Code.
Wastewater System Description: ���✓✓ Wastewater Flow: �
Faality Description: �o �—, s W!� New 4�
Basement? 4 Yes Cb�Pd'o Basement F"ixtures? O Yes o
Wastewater Svstem Requirements
�g.p.d. Type: ,�
�D
Repair a Expansion ❑
Tankage: Septic Tank size /DO p gal. Pump Tank size ""' gat. Grease Trap size gal.
� .� �a�
Trenches: Total lengfh �'�0 ft. Trench Width �i ft. Total Area `�r_�_sr_9—�q. ft.
Max. Trench Depth: � D in. Aggregate Depth:� in. Soil Cover. �_ in. Trench Separation 9 ft, on center
Permit Expiration Date: `Z�" �7' �d �
Authorized State Agen - � Date: �� v7 �?�a /
"See attached site plan and addendum pages r additional permit conditions.
The type of system permitted O does s not d' er from t e type specfied on the pplicat'
specifications of this permit
OwneNLegal Representative Signature F Date ' '��
Oaerafion Pennit
1 accept the
System Type �n accordance with Table Va) ,�_ �
This system has been installed in compliance with applicable North Carolina General Statutes, Laws and Rutes for Sewage Treatrnent
and Dlsposal, and all conditions of the Improvement Permit and Construction Authorization. Issuance of this permit implies no
gua tee tfiat ths sy m installed wiU tunction property for any given period of time.
� ��
Authorized ,Stat A t � Date �
9
PCHD, rev. 03/07I01
�
r
Parson C�ur�t�/ Heaith Department
Es�viro�mental �deslth Seciion T� �� �: -0
� � � p�rca! #: 3 t�
S�i'� S14ETCH .. . .
o� ��� �� � ��
:;�: Subdi sion/Sectio i#
: ��
�1�
Sya�em conrpone� represent appra�cimarte c:a�tours oxly. The ca�or mus�t,�log the sy�steae.
prior to � die i�r�alla�ioa to i�.run that proper �rada is raa}�itai�red
I�
�
N
Scale: � ��- Sd � —
io�
j �457 07'
5D,
�-�i , s$ �
G� � d.�-�� o.-r� �� •
N
W
S
�
��o'�' -��.,/c.� ,�orlo-yS
�� • G�i✓f� o�✓ Lo.✓rod.e
• �,q��✓>�.�✓ Sfr��S
- 7�-�jl ?>i.5r
"2o�cS ST>
W�,.� ���
� ��
�'� ypD
0.3/ �rg-2
1,�0�,,�,�3�' sq �r. '
�fda �tQ' l�/• GT'
�� ��-»90 ,� �� �.� �y y��sr,o,�s �-
Person Counfij Health Departme�t
/� Environmental Health Section �/ �
Tax iNap #: � l U Parcei #: 4�
Zoning: Township: -F�Q_f � � �e�
Subdivision: � Section: �_ Lot: / Z
Appiicant• ��
Location• '
O eration Permit
System Type (In Accordance With Table Va): .J---
THIS SYSTEM HAS BEEN INSTALLED IN COMPLlANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AU ORIZATION.
,� % ��l -�a
uthorized State Agen Date
PCHD, rev. 10/12l99
��� S .�C`" ��� �� � �D � . �� 2 � �
�,� ``' � o o � �..rrQ�K lNl//�yrC.
������
�sa�na-o�aT-�*-n �aa��11 ����.7L�7�a � � ' ° �e ' � �� "d Z
Well Log
p��; ���� �� s Tax Map � Parcel # 3� D
Location��—� �
Subdivision: c Lot # �
Well Construction
Distance From nearest Property Line (Minimum 10 feet)
Distance from Septic System (Minimum 60 feet)
Tota1 Depth: ��� ft Yield: l� GPM Sta 'c Water Level: �_� ft
Water Bearing Zones: Depth !7 . � �ft �ft �ft ft
Casing:
Depth: From � to �� ft. Diameter: �_ in
Type: Galvanized Steel
Weight: ckness: ./i�g Height above Ground: �_ in
Drive Shoe: �/ Yes No Any problems encountered while setting casing? _
If "yes" give reason:
Grout:
Neat: Sand/Cement
Annular Space �dth
Method of Grout: Pumped _
Materials Used:
Yes _�Qo
Concrete GraveUCement
inches Water in Annular Space Yes No
Pressure Poured Depth to
No. Bags Portland cement Weight of 1 Bag
If mixture (sand, gravel, cuttings) — Ratio to
ID plates: Yes No 4 x 4 slab _ Yes _ No
Drilling Log
Pounds
Location Drawing
��� 5 ez
��'
Ft.
From To Formation
v� ;;
�
� o
� u���, ry 1�''
, . �� � ����!
�� ��� ,I�
� /� D�
� V
P�"�
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 Departm t.
Signature of Contractor C� C� ID#, �2�/ Date �-��/-D�
PC'�iD rev O1/16/02
#... ._......
���St�R! �L�ID�VT''f ��1lJIR�NMIE�I��1L �-iEa�LT1-3
P�.�.�,�E S�� s��AC�Ei3 4��►N Ft�F� �l/EiL SiT� l�A�IOU�'
Taa �Aap �
}� �- 0 ��� � 3 � 6 . .
Zoning Tow�htP f! [.� � ► V ( �/
x� .,•... ......
�a� � .
��: � �u�����
� � �
�ry Q �;� s«�'. '.�-7�- -
�pe of y4fater Suat�lti:
Reauirements:
Wel! Permit
�ndividual Community Pubiic
Site Approved by �
Grouting Appsoved by - `D � .
Well Log r/
Well Tag _
Air Vent
Hose Bib
Concrete Stab
Well
Well
. - '1.�.:1►r;r: �
. . . _ . - ��►��.�. I �
Date: ���' �a
**See Attached Site Sketch**
Wells must be 10. feet from property lines.
V.yells must be 100 feet from septic systems.
Wells must be "af least 25 feet from any building foundation.
Other conditions: � �
PCHD, rev.11/29/99