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Applicant:
Location:
1
T� x M:� � P,rc I#
S�ubdivision �.,�J. ■ i!! /. '�
Fh��s�e-`Section:`Lot # �
� Imp�ove�ent fl'er�t
Permit �alid for F'ave rs � 1Vo Ezpiration /
Type of Facility .3 New �Addition �Vater 5upply 11/�%��l
# of Occupants # of B drooms � 3 Projected Daily Flow g.p.d. -
Proposed Wastewat System: � e� �— Type: ��
Proposed Repair: p� ,�/�� Type:
Permit Conditions: �e. �'i�� �iJ�►�.�P�'�/1 '
Owner or Legal�
Authorized State
Date:
Date: — —0
The. issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicanbproperty 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 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 Sewa�e Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental �ealth
Specialist warrants that the septic tank system. will continue to function satisfactorily in the future or that the water supply will remain
potable. _ _ ___
� Auth�r�a�on to Cons�uct i�astewat�� Syste� �Itequirecl fo� �uilding Permit)
* See site plan and additional attachments (_). ��
Propo,s�gd Wastewater System: 1..Q11�,1�✓��f d�--� l Type �a Wastewater Flow ��y� g•P•d.
New `� Repair Expansion Soil L'I'Alt: c'� g.p.d./ ft 2
Type of Facility: ��tg�- �-� � Basement Yes � No
�astewater System Requirements
Tank Size: Septic 'Tank: �� gal Pump Tank: gal Grease Trap: __ gal
Drainfieid: Tota1 Area: ��.sq ft T'otal Length �Q� ft' li'Ia�mum Trench i)eptli�����an
T�ench �Yid#h 3� ft 1VIinimum Soil Cover: �_ an Minimum Trench Separation: � ft
Disirilbution:
5pecificatioais:
i� Bax � Serial Distribution�
�P,�.�O�n ���,n-. a �-
Authorazed State Agent: �
Permit Exniration Date:
Pressure Manifold
►r
Date: ���C�"�� -
The type of system permitted is v�Conventional Innovative Alternative. I acc�pt the specifications of
the permi�
�wsaer/�.egal �ep��se�atative: � Date:
PCHD 1 / 17/2003
1
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Applicant:
Location:
. �,-. -
5
e
T�x M�p � P�rc�-el # .
Su�bciivision r� .� • �. _j- �
Phas�e Sect+ionlLot #
# of Bedrooms
a
�
i.J 7 101- v� ( C./ � �/
G� C tl��.Z �0�2.� _
- �erat�on Perm it .
System Type (In Accordance With Tabie Va): �
THIS SYSTEM FiAS BEEN INSTALLED IN COMPLIANCE WiTH APPLICABLE NORTH
CAROLlNA GEfdERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIOiVS OF ' THE IMPROVEMENT PERMIT AND CONSTRUCTIO�!
AUT!-ipRiZATiON._ _.
nt �
Installed By:
s-a ��
Date
Date: g -a7-fl5
PCHD, rev. 07I29/04
J
�E�TiG TA�IK �N�����'1�.h� �I�ECKLIS�' (i'ype i9 - I�l1 -
Tax Map # la �-Ic� Parce! #��.05 Sys�em Type (Tabie Va) �C�,
OwnerlApplicant Subdivision '
Address/Location Sec/Phase Lot # 7S
Septic Tank Initial/Dat� IVitr� �cation nes Ini�a ate
,
State ID/date 973-/y� iz-� s 7�o Trench Width � 3 ft. S•Z�oS '
Ca aci -� ai. �� � Trench De th in.
Tee and Fiiter ✓ T,renct� Len th Lt1 ft.
Baffle Trench Grade � �
Sealant Tcenct� S acin
Riser ifi a licable �� � Rock De th and Quali
Tank Out(et Seal Dams/Ste downs etc.
Permanent Marker Pressure Laterals �
. Pump Tank Hole Spacing
State ate o e ¢e
Ca aci aL q� Pi e. Sleeve
Wate roof /Sealant Tum-u s/Protectors
Riser Required� Setbacks
Water Ti ht From Wells � ��- ��t
Pump From Property lines
Check Valve/Gate Valve Structures/Basements ✓
� Antt-si on o e itc es ra�na e a s
Floats/Switches Surface Waters
Alarm visable and audible Public 1lUater Su lies rv �
Electricai Com onents Vertical Cuts >2 ft. ✓CS S a�s
� Rate m Water Lines
A roved Pum Model Vehicle Traffic �
Block Under Pum Ad'acent S tems �/
Pum Removal Ro e/Chain � �Ea�ements/Ri hf of Wa s
. �Distribution. System Other
� Serial Distribution S-�� Easements Recorded
� ressure ani o ert� e erator ontra
Low Pressure Pi e Tri-Partate A reement
A r. Pi e I�taterial and Grade
Valves �
� Comments .
pcf�d rev. 3/13/�1
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' � 'c� � �CTT�T�� �,�,��,.,p��,�,1� (-�
�na�-n���a.��+�-�+�aa.��.�: g���.��1in. LX41l51J LJl(UUU�aI.I ��-'/ / "��
`/ Grout Log
0��: ��,�1�..crn�o Tax 1VIap��ld Parcel # �:SC¢�
Location:
Subdivision: U Cl2�eS Lot # �_
Well Construction
Distance From nearest Property Line (Minimum 10 feet) ��
Distance from Septic System (Minimum 60 feet) �a0
Total Depth: � C� ft�eld: � GPM � Static Water Level: c�5 ft
Water Bearing Zones: Depth � ft ft ft ft
Casing:
Depth: From � to 105� ft. Diameter: � in
Type: Galvanized Steel �—
Weight: Thiclrness: / 8� Height above Ground: � in
Drive Shoe: / Yes No Any problems encountered while setting casing? Yes �o
If "yes" give reason:
Grout: "
Neat: Sand/Cement Concrete GraveUCement �
. Annular Space Width inches Water in Annulaz Space Yes No
Method of Grout: Pumped Pressure Poured � Depth O to c�U 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 �s _ No
Liner: - <„
Depth: Date Installed: Grout: Installed by: _
Drilling Log
Location Drawing
From To Formation t!
`7 Ca � �
s D `-��, �'
o a�v ��� �
. s°� �
. �� �
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_�_ /� /
Signature of Co�tractor � � ID# �� Date �' '� 7-6 7
_ �
Pump Installment
Pump Installation Contractor: � �JL1'e� State Registration Number: � CC� �{ -
Pump Depth: �iC� ft Stati Water Level: c� S� ft �
Pump Make & Model: � Z� Pump Size and Rating: /o'Z hp �� gpm
I hereby certify that this pump was installed and the well head completed according to the Person County Well Rules in effect
on this date and that a copy of this record has been provi d, to the well owner. .
�
Pump Installer Signature � �� ���`��� Date: -�`���? ��� PCHD rev O1/27/04
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�Pln�a� ---� , w .v s
Snbdieisio�: ��n� �V�S Seetioa: I.o� s
'�'�� of Water Sa��s�r �IndiPidxzal Communitp Publi.c
R�a��aarcfficmm�- '
,
Site .Approved by � �
Gmuting Appmved by � �( �� b��
WeIl Log �
�Pell Tag ✓ c �
�Air Vent � ✓ - ?-d5
Hose Bib '
Concxete Slali
We9�. D�r l�,rn ef�e .
W�1 �ro� �g�: D�,�: S -2 7 -bS
'�ee Attac�aed Si� S�etc�a�
Wells must be 10 feet from PrOP�-Y ��-
Wells must be 100 feet from septic systems.
WeILs must be at least 25 feet from any bu�ding foundati.on,
Ot3ier conditions:
PC.HD, sev. 09/07/01