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A40 362Application Date: �.z ��'7 Amount Paid: 7,S•� Receipt #: ,af,�f O � �� Jl �ll�l.� �� "� � � �� oaa-��-� ��.Il ZL��.W.II.�� APPLICATION FOR SERVICES Tax Map #: /�� Parcel #: 36� IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT. FALSIFIED, CHANGED OR THE SITE IS ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. 1) Permit requested by: (Ownerlagent/prospective owner): .�0�.��i� �4 La � m � �i/rt/�4 �� /��iP�l S-' Home Phone:336 "��j'7 ;�LL`� Address: �06 vC Business Phone: 3�l -<SU 4�� 8�i ��/� ��.�` 2) Name and address of current owner: _SA�? . � 5 �4 f3 z� V� �,�t-2/dC/L 3) Property Description: Lot size: a*5 7 Township. Subdivision: �i� Lot # Directions to the property (Including road names and numbers): �,4 �i.�� T� 4) 5) Proposed Use and Structure Description: answer ch of the following questions: a) Proposed _, Existing , Type of Structure: ��vC� Width: Depth: b) Number of Bedrooms: "� � Number of occupants or people to be served: c) Basement: Yes_, No ✓ Will t re be plumbing in the basement?�D d) Garbage Disposal: Yes , No _ Water Supply Type: Private �/ (new ✓ or existing�, Public_, Community , Spring _ Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the site plan. 6) Does your property contain previously identified jurisdictional wetlands? Yes_ No � PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. -, ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAFCED OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF. I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for the above-described property. I agree that the contents of this application are true and represent the maximum facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. �y/ U Date PCHD, rev. 06/27l02 .��,�� lt J.�dll'�l� `ul �7 . . � � �U l��l �� ZE�m�na-m,r,�,r,r*�aa.�.11 �c�.lL�II� � SI1'E. S�g�.TCI� Natne �`��''� ��'� . Ta.g Map # �b .Parc�l # �b`� Subdivision � Section/Lot# v� , -� �� .tluthorized Staxe Agent � � Date . � System components represent approximate �contours only. The contractor must, fTag the system prior to beginning the installation To insure that�iropergrade is masntained �� c� a � -i = W -t c-mi� �� o o(n ppr �''Z o� � . � o0 D (n � I W � �� O D w ' 2 Z � I C7 -I . rn I �` ` �� ` D � I G,� tn fTl '-+ � p N _ \ � (nZ I � �L \ O �7 � �' � � \ (� n �7 -< � O O �� \ rn� or � N05'29'46"E Z �o r� -� � 323. 71 � r ,� � ' TOT � � _ DZ W �---� N � — Z O ---� � — � � C� -I �7 N �p � -- — � cmn � m � � • o � � ,5£` ` \ \ � � � . z ` � �' � � � f � ,� w cN � S � �'� '� C� N � \ � � V / � N 1 � r � ,A N 1 �\ W � � O Cn O ` � /`� • D < ' • � ' � ". N W � . � \ N J o � � -Z1 � � w p Z � - N � � � ^� .-� \ � � �' Z7 � 1 " � � �' � � � � �rn � \ � S�Z�S \ \ \�' c�i�a � Cn � 'Z u , `� � ` \ _ C7i . `��, � p W � � \ ` � n W � \ O � '-' -f \ 1 'il � \ � n .yy.] (O � . `` \ ! � \ � � � � �� \� � � C.a _. +� n � i � � � � �' �` ''' , G N. �'' V� �� \ � \ - N � • � i ' �O � � � � \ i �T1 � � � � � O i �'' � � �`' � \ , T � ^ � i �' � �1 � . � � � � ` ` O /V � r � � �" s � � \ \ z (�1 ,..� Z � c� �-. � v' � �-' � \ �� z � � � "� � � A \n �. �- � � � n �� N�� ' c .�.. �s'^ � � \ \ \ D J� z � c� a � � "' R �' � � o ^ � � � �.�,.� � � � � � � � D D � � �,�� . � � �, � � ^ �, . I I ' � �" , �.�, �� D � _ . , _ j -' �L T � -��'' C.1 I " � � d1 ` -� —L r Z � �� . �' `� .� � � � 0 � � � n � � � � � � �� ' � �' v� � `�` ,� �7 � � � � � .� s�, �� r �- � C� � � � � - �= -< � _ _. _ __ _ _ . _ _ ____._.. Page 2 of 2 Profile View of Pressure Manifold for Level Site Installation � (not to scale) 3' tYrnch Plan View of Pressure Manifold for Level Site Installation (not to scale) tb(� r �� http://www.deh.enr.state.nc.us/oww/LOSWW/manifolds.htm 8/28/2001 NEMA 4X Simplax Contml Pazul x I-1 4" X 4" Prees�x�e Treated Post � Sloped To Shed Water 12" Separation � Electrical Cox�uit -- 5" Cover • ' � Accese Cover. � •• • . ; � 1 � � • � r . ! .. ,. , ` �� - � , •t ', � . . �,, Opening F'il1ed With Anti Siphon Ho1e P land C G:ou � Inlet From Septie Tank ort ement t �� g�� 4" SCH 40 PVC Pipe � �� Valve � �P� F1oat Wixef ' � High Water Alarm Level ; � ' (6" Separation� , � , Hish Level - Pump On � �. �� VaporLock F1oat� .. C( 1 /( �Draxdo4m �Up H�71) + � rt..Removable '.:' '; /„_ � r. , ' .� F1oat Tree �� . Low Levcl -Purnp Ofi , ` , Putnp .: ,: . Preca�t Concrete Tank 4" Concxete ' ;.; (Matezial Stre h y3500 P Block ' I " ' �•�. ; • � • + • � ' - � ' . . . : ' ' , : . . '� � . • \ - ti � . ' •' • � , O� C� � GALLt�N PUNg' T�NK Ihut Seal Both Ends Of The Gon�it �- 24" Mininoun ,..,.-, •. , Tlaeaded Gate Yalve ; Coxicrete Riser 6" Sepasati,on ' • '. • . :r..J• f' . — '�rPortland Concrete Crzaut _� ll'�dtt]C • ' � Zip Co:d � � Opening Fillad �iT'ith Ties Supply �: portland Cement Gx�ont Line • • ' Oatkt To Disttabution ;c.Nv1�„ 2" SCH40PVC Pipe � .�`�� r �`�� M Tax Map #: APPlican� Subdivisiori: ��. � f �� '--' = � c� � ZCT�T�C � ��7��,.-n-.v,f-n �9�L.�.J1 ��.JL'�113 WELL PE�T� 1'I.EASE SEE A�.'T�CHEI) PI.AN FC�R WELL SITE LAYOU'T � Parcel # � �`'� Townshi � \� �' � r vu � — — p ,� F�Y'�,� l.�e/--c�t� �' �� YYiS �, T�e of Water Suvulv: Rec�uirements- �dividual Communitp Public Site Approved bp � Grout�ng A�f'proved bp ✓ Well Log �/ ,/ ' � � Well Ta.g; Cl� Air. Vent � V Hose B� Concrete Sla.b J �v - L �1 L%.r i �� . �'� - � . � . - . : . .il�..r/ L.► � . '�5ee Attached Site Sketch'� Wells must be 10 feet from propertp lines. � �Wells must be 100 feet from septic systeins. Wells must be at least 25 feet from anp building foundation. Other conditions: -- PC��, rev. 09/07/Ol 0 Type �dI (b) Systena �spection Checklist Tax Map � Parcel #: 3�pZ PIN Owner: Subdivision: Address: Ph/Sec/Lot: Location: YES NO Remarks 1)-Establishment_ __ _------ -- -- __ . _ _ - - - _ a) type, size and sewage flow in � [] accordance with permit 2) Tanks a) tank risers accessible and surface water diverted b) tanks and access manholes structurally sound, watertight c) sanitary tee(s) in good worldng condition d) tanks pumped, cleaned out as needed 3) Effluent Dosing System a) effluent appears clear, free of excess solids b) required pumps present, operating properly c) high water alarm present, operating properly d) floats, pipes, valves, disconnects in good worlting condition, operating properly e) control panel enclosure and components in good condition, operating prop rly fl Drawdown rate: �` 4) Ground Asorption Field(s) a) no evidence of effluent reaching surface or surface waters b) surface water being effectively diverted away from dra�eld c) diversion ditches, swales, tile drains are well maintained d) soil cover, vegetation adequate and maintained as needed e) protected from traffic and destructive uses fl distribution devices in good condition, working properly g) repair area properly reserved, maintained h) pressure head properly adjusted , �� .� Summary of Improvements and/or Repairs Needed: Authorized Agent Date �� [J �- �``S� ' �59' `� �� 0 ' r- �=-��,j,�� I��ng-��.��.�.�►.Il u 33L��.Il�11� Applicant: Permit Valid for � Type of Facility: � # of Occupants�� Proposed Wastewater Proposed Repair: � T��x M�� ' P�rc�el � Swf��fivis•ion Ph��s�e Sect�ion Lot # ii � Improvement Permit Five ears _ No Egpiration � New 'V Addition Water Supply �_ C� # of Bedrooms Projected Daily Flow �� g.p.d. V• Permit Conditions: � . S�� c �� Owner or Legal Representative Authorized State Agent: , Typ.e: Type: Date: Date: �-�— � The issuance of this permit by the Health Departrnent in does not guazantee 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 Perinit Is subject to revocatIon�tf the stte plan, plat or the intended use changes. The Improvement Permit Is not affected by a change in ownerahip of the property. This permlt was Issued in compliance with the provlsions of the North Carolina `Laws and Rules�or Sewa�e Treatment and Disposal Systems' (15A NCAC 18A .1900). �` Authorization to Construct Wastewater System (Required for Building permit) * See site plan and additional attachments (�. Proposed astewater System: l.P�,iL{! • � Type� Wastewater Flow ��.p.d. New . Repair Expansion _ Soil LTAR: .� G �g. .d./ ft 2 Type of Facility: Basement _ Yes ./No Wastewater System Requirements Tank Size: Septic Tank: ��(J�Ogal Pump Tank: � gal Grease Trap: gal Drainfield: Tota1 Area: l�� sq ft Total Length � 0 ft Mazimum Trench Depth � in Trench Width � ft Minimum Soil Cover: � in Minimum Trench Separation: � ft Distribution: Distribution Box Serial Distribution Pressure Manifold Specifications: Authorized State Agent: � Permit Exviration Date: 1■ Date: `� � / � � � The type of system permitted is �„�Conventional Innovative Alternative. I accept the specifi tions of the permit. �� Owner/Legal Representative: (��2�,/�.V 4 Date: � � --- - ----.�.� �1�, ; , �� J' �� .� � � � �� ' zcn.v�-n�-�saa-na��rn��.� ��.ta.�� Ta�x M�p %� Su�bcilivision F�rcel # � F'h'�e�S�T�'c't�ion Lot # # of Bed�rooms Operation Pernn it � - 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 CONSTRUCTIOM AUTH IZATION. � �.�-�C (��'V�e/ �r`G� —D uthorized State Agent Date , ` �� instalied By: w ' ��' �"` � . `� � bate: �rl � ►n't.�v►� P� � l,� � � �� -� � ,�-�� ( �� r ��. ��. � 3-�-os� � �nn � an rc=.�i�� !�el• :i :' � � + _� t - ��M'�ii !�� -i� 1`~ :il�►•T�-� IFt{ I�-''= •'t't= -�l-� .s� ��r_ f; ia�y� i— • • •I1��1�.• �a I��I• �:;• ��! e ��_=:_ti�� f L� � Y_; r .. � _ '.. a. _. ��! �i_-,�s3• E�� ir'� t i :�-rt 1• i�;s ' f< �"'�;�1 �� i=--�'_ � € �1 •' — ��,— ', �-i�=.�r_ _ e.• C� , �;.1�_.l'i¢=i.=:� u•i.i;,�; y _' � r_ ♦ t ti (_ r;o_'; �� -.r,.•-_ r—.ii. •��C.�`i� '[��+•,� _ ='1!'=f1'= ��'�� •: •:.-_:. -=if1'�=-w!;� ��a��E�� r�-w �r� e��t �s l�.�:_��c:�� !_1ttr-l�_ _.��E=.=�t!'�=1 BarnetYe Well Drilling Inc 336 598 9275 08l06104 03:51P P.001 �.�� S f .LC"" �� D � �O :2 �L � ,,. • � c� ��I�"1C`�.' �� ° �. : ,,.�..�� L-�'�1 / r�cc. � g.a.�aru�c-�sca,•-••,, .o�ntGta.� ��•�Il�.�. L1t31151�/ LNUTAll3lgl � " �ff `Z.'�— ■ Owner: Location: SubdivisiOn: GiOu�t IaOg 'rax Lot # Parcel # Well Co�ustrnction DisL3nce From nearest T'roperty Lin� (Minimum 10 fcct) Distancc from Septic System (Minimam 60 feet) Z'o� p�p�; 1�/� ft Yield: �_ GPM Staric Water Level: �_� �t Water Bearing Zoncs: Deptix,��` � ft � Casing: , Depth: From D to ,��_ ft. Di�meter: � in Type: Galvanx7,ed Steei Weighr. iclrness: � 1S� �ieight above Gxownd: /�/ in D ri v e S h o e: ✓ Yes �To An� problems encountered while setang casing7 �es �Na Yf "yes" givo xeason• Grout: ' Neat: Sand/Ccmcnt,_� Concrete GraveUCement . qnnular $pace Width inches Water in Annular Space Xes �No Method of Crmut: Pumped �ressute � Poured ✓ Deptlx ,� �_ to �_ Ft, Matcrisis Used: Na. Bags Portland cement ,4 :�.iY� Wci�.hi of 1 Bag .S'� Pa�mds If mixtiu-c (san� gravei, cuttings) - Rat�o to J.D plates• ✓Yes _ No 4 x 4 slab �/ 'e5 .,,,,_ No I,iner: D�pth: � From To O y ]]ate Installed: Cxrout: Log t I hereby certify that tht above infarmation is cotrtcC by the Person County Health Departme�t. n, Signutui'e Of COntracfor InstaIIcd by: Locaiaon Drawing this we11 was consixucted is1 accordanee witli regulations set forth Yb # ,�� Date - � ' Pump Iastailxuent ' Pump Izastallation Contractor: , �n ��► �cl% .�� . Statc Regis�ation NumUtr: ��i, 4� p�p ��p�; / ft Sta#ic Water Level: � ft Pump Make & 1VIode1' ` . � �ump Size and Rating: �whp _� gpm ; I hcreby ceriify that this piunp was ir�stalled and thc vsrell head co lctcd'accarding bo the Pcrson County Wcil Rules in effect on this datc and that a copy of this record as been �de e wcll ewncr. . Pu�onnn Installer S's�nafiare . ._._.`_. Date: �-� -c�Ei PCHI3 rev 01I27/Q4 � F � �� -� �' �� . � �� j� IS'o� W' ��i5°n 1 t�tQ.k c r D u1" •` -r `� �'� �'L( Sa W� W � � �� '�� qk� a� �,�';��(� �s � o,� �f� s {'lG �T1 ' l� -Y�or� i n�a ow �n � � �,�,r.,P r��• `��''� i ��1� �„� v,s� ,o PP�4�� °`�'° w�� 1`to-t� �ad'{ o4d�'q„ ��S�c'� S�w�� O t�c�--S Q� � � a- � � ��e �� 1� P��`t • . r-- �O ��5� r� '� � ��sS�p�Ea-xtr�• '•. �'-- y--1 `�- �►�t� o'� �i�-`�.� '��o S��P'��4 �. Q w �