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Pu�iic_, �r ..,.., sP�'�p _ . ���Y �+� � p�ert��Yes_ No _... IiY� F� ��p+�oc�c�s torc�cn an � a� pi�. s � • . �� �a�s !�» pnaprl� �Io p�vi�gy 1�■�d Iu� �? Yas _ No � ►�..��� N�7Ts Tt� �� �• . 3� A Pi.�►T OFTFE �y' ��T.E PIJ1N IYJ�' �� WR}i'i�118 APPUGATM�i; . y �nr �s �w� c� �us�r �e c�.��.� rwr�n. �� e�oPos� t,.oc.�►�a a� n�.,�.. �-r�:�� r� �� a� �►cx�o. �'� � tw�cr ��►u�,v �►� �.� gv�►�.uw-r� eY-rwwe t�u.Tt�t u�+�r�°r sY'�. 1- it�sffi� rttslo4 a�p1�n tic flte ��+o�t Cowrt�l � pe� ti0t a� e�l�bn t6r il�tr� cp-ai� p�upa�� � �Y�'n f�r tt� ata�e�-,r�ed p�rr��y, ��Q ytaat ih� � a� ttti� a� are htis and rapreeer�t 1ne mpcarutrt� �'��tea Go ba piaoptl an #� p . I r€ ttue � ia aii�Ol ar 13�e intende�d uma ct�tges, tha p�rt� st�all � tnv�d, /� ��� .� t�a! � � �'vrr�rrt-� . �( � Zr.�``'-t-� ,��. •7 ;;Zc •-�' � �W�18t Ot' ��j ��-�yE` - �8�3 PCiD, t�ee.10tt7�'1 � �—�����,� ���� �� �. "^ � � ���� I��.�a-��,.-n-n ����.11 I�1L��.Il�I�3. Applicant: Location: Permit'Valid for D'� Type of Facility: # of Occupants t�� Proposed Wastewater Proposed Repair: C ��x M:a�� � � P�.r�c = I # � S�u�bciivi�sion ! ��,i� ! � � Ph.��s�e-'Sect+ion-'Lot # � � _ � �p�oveffient Pera�t Years � No Ezpnration � # of B System: � New �Addition Projected Daily Flow �F'� Permit Conditions: �'�- Si� ��G�v� � Owner or Legal�Represe Authorized State Agent: �ater Supply ��l g.p.d. � -�-�` Type: cWi`cl Type: �q Date: � ✓ j7 �� 7 Date: � '- The issuance of this permit by the Health Depaztment in does not guarantee the issuance of other permits. It is the responsibility of the applicant/property 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 `iaws and Rules for Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic tank system. will continue to function satisfactorily in the future or that the water supply wilt remain potable. - Author�ation to Cons�uct Wastewater 5yste� (I2equired for �uilding Permit) * See site plan and additional attachments (_). Propo ed Wastewater System: �pM,tle,n�cvVt�'l Type� Wastewater Flow`�� g.p.d. New � Repa.ir Expansion Soil L'TAlt: ��� g.p.d./ ft 2 Type of Facility: �j ��. Sasement Yes D� No �Vastewater S�stem �tequirements Tank Size: 5eptic'Tank: �-� ga1 Pu�p Ta�k: gal Grease Trap: gal Drainfield: Total Area: �.sq ft 'Total Length 3� ft 1VYa�mum Trench Depth ��' an �'�ench �idth � fft 16�Iinimurn Soil Cover: _�_ in Minimum Trench Separation: �_ ft Distribution: Distribution Box � Serial Distribution Pressure Manifold 5pecifications: Authorized State Agent: � Permit Exnirati n Date: Date: �-t'���`�� The type of system permitted is Gonventional Innovative Alternative. I accept the specifications of the permit. � Owne�/Legal �ep��sent�tive: Date: � l � PC 1/17/2003 �� � � � . �- 3�so �� �.��N . � sa ��� 3�so�� �.�ot� � o� u �L l. M/ � � 3nN3n� 3��bs b� � ��-�s � � � l � �OL'L91. M« <L �,LO � ��� _ :-I 3 0' � �$�. �o 0 s0��5 1�ti1,2 � � _-- �u�p,Lti.LaS ��L"L9 � ,'. �� � � �; � ���� �- � c� �� � ��� � �s�u���� I� � ; � � a�� o� �, � �' �p P�� - � ^, • ` V .O� "C. G 'S'� � � � lt� s`� /� N N cv �Q �w. vv�� t', ao �5� � � � L,� �p � bZo�. '� � 1 t �a��f- � �_ �� `�� V, � � ` �_ �9�'�� �. 3u60,L �LON rn � L ' :� �ZL'9Z ��. ..��} 3�6t}�L �.LON L tr 1 .,.,�+. � , �. . �;��� � 6� W � �Z ���� �� ���� �� �.. o ' . � � � �� 1L � � �..�aa- � �.a�rn. ����.I1 IF�L � a�.IL�IIEn. Applicant: Location: a ` • ,,, ` ,. , • ; �' „ Tax M�p ('�,rcel # Suhciivision • �' - :, r. Fhase Sectior� Lot # •. # of Bed�rooms System Type (In Accordance Wiih Table Va): �0.. THIS SYSTEM H,4S BEEN IIVSTALLED IN COMPLIANCE WITH APPLICABLE iVORTH CAROL11�4A GENER�►L STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL, AND ALL CONDIT10iVS OF TFlE IMPROVEMENT PERMIT AND CONSTRUCTI�N AllTHORIZATION. � � ���� ��- . Authorized State Agent Installed By: � )iinmu /.Pu ) is 5'(0 ��� �'� �5� i (�� - Date Date: � �/ �3� ��7 �t IS- l �e � �CF3— F� ia- l -oln L � = CoB�.� � Z = 83� L3 = (��k �—�t = I�l �.� �s = 8u �� �{ z ��+ PCHD, rev. 07/29/04 �; , � �E�31C �'�K iN�PE�YIOBd ��IE��LI�T {TYPe 91- IOd� Tax Map #�4U Parcel #_ �a System Type (Table Va) T.i� OwnerlApplicant Subdivision C��r`�c� AcYes Address/Location Sec/Phase Lot # 1��: State�ID/date � ��� t�-1 Capacity `�� �c�� .gal. Tee and Fiiter Baffle Sealant Riser (ifi applicabie) � T'ank Outiet Seal Permanent Marker Pump T�nk ISealant Riser Water Tight , Purrep Check Valve/Gate Valve nt�-sip on o e Alarm (visable and audible) Electrical Components Rate (gpm) Approved Pump Niode( Block Under Pump Pump Removal RopelChain . � Distribution. System Serial Distribution ressure ani o Low Pressure Pipe Appr. Pipe I�/laterial and Grade Valves ► 1�lltflilcatlOPi � Trench �dth� � Trench De th T,rench Len th Trench Grade � i� � Rock De th and Quali i Dams/Ste downs etc. Pressure Laterals � n►1 a Hole Spacing � Pi e. Sieeve Tum-u s/Protectors Required� Se4�acks From� Wells ' rvl A From Propertv lines 0 • � Surface Waters Public VNater Su lie Vertical Cuts >2 ft. Water Lines Vehicle�Traffic � -Ea$ements/Ri ht of V Other ►l� Easements Recorded e ie erator o Tri-Partate AQreemen Coonta�en� � �-� pct�d rev. 3113/01 d � ��,�.��. �''_1��.��� --, �._..�- � � ��-��- ��...���.� ��.� ���.�� �� ���� . ��� S�� ���� �� ��� ��. S� ���� T��� #: %��-o ���# 3� ���� ��� s��o�: s���: �� � �� 'I'�e of Water Saa���r. �Individual Communitp Public ,, - . - �,: ,- �: ;ti Site .Approved by �� A r" � �e-���( ► 1 �_ ►�� � 1�/!��� Yd l.lt i t � ( S'1 .� v�t . � l� ��� Hose Bsb ' z7 `� (1�-�V . ,�v� � r �� � �11'�� Concrete Sla� ' ✓" `" 7 � �� -(o--U�I g s w� ��: ,�a � ��� , � � .� � . . � ��r/ �o„ w� ���� ��: �.�Cp �, �� ���: �/z��;� s/� o�!'�� - �'/1�P�- Lo '�ee 1�xtac�aed 5ite Sk�s�a� � °"'` s���� T Wells must be 10 fe�t from PzOP�-Y Iines. /I'� Wells must be 100 feet from septic systems- . WeItss must be at least 25 feet from anp building founda�ion, Other conditions• PCi�T?, �v. 0�/07/01 :>= --� --: �:-- . Q Q 2 oa�o� � _� � � _ ..� ...` :,c,_,,. . . r��� �:,1 : ������....�� .: y� . �:� ;- .: � Gl�a� �n� W�l l :.;;:�:::::::�: � ��.- .� :: ;�:����� .:_ ��.-�,o:�,�P�� ��,.�.��� : D� Ou�! _�- i�_ o? - . .. r Grout Log - Owner. - /r.jT-C -��o � �O � t..�... " Tax Map � Pazcei # ��L I.ocation: � - Subdivision: � � Lot # � - WeII Constrac.bon Distance From nearest Properiy L"me (Minimum 10 feet) Distance from Septic System (Ntnnimum 60 feet) • Total Depth: � ft Yeld: ZO GPM • Static Water I.eveL• � ft Water Bearing Zanes: Depth � ft fi ft ft Depth: From (l to � ft. Diameter: in - Type: Galvanized Sbeel . � . Weigh� Thicl�ess: Height above Ground: _ in - ; Drive Shoe: • Yes No Any problems enco� wh�e setting casing� Xes _ No � If `�yes" give reason: . ' � Gron� - . . . . _ Nea� Sand/Cement Conctete GraveUCem,ent . --. Annular Space Width • mches Water in Annular Space Yes ' No .. Method of Grout Pum�ed Press�u�e � Poured � Depih ' to Ft Materials IIsed� - . No. Bags Portland cement ' Weight o� 1 Bag � Poimds . . If mufitte (sand, gravel, cuthngs) — Ratio to �� IDp�ate�_Yes_No 4x4slab_Yes_No Liner. " � _ � Depth: ��- C� Date Installed: � l� Grou� "� Installed by: � h'�[t/� f � Driiling Log Location Drawing I�om To Rormai�on . • a Z , _ . s I he�reUy cettify that the above� i�rfoimatiau is coirect and that i�is well was c��ns�u�d in accordance with regulations sex forth by the Person Counfiy Health �, : . Siguatare of Contrxc�or - ID# 2 i' Date =�F-,�- � - Pamp Inst�Ilmeut Pnmp Installation ntractor. State R,egishation Nuinbei: � P�P �P�: $ Static Water I,evel: ft Pump Make & Model• Piunp Size and Ratin�- hp gpm I hereby cemfy t�at t�is pumip was instatled a�d the well head completed according to the Peison Co�r Well Rutes in effect on this date and tbat a c�py of t�is record has been pa+ovided to-�e well owner. . �p ��' �'e ' � . . Date• � � PC� rev O 1/27/04