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' , • : �� - � ���� f .��.aza� � _i: `��IL!. �� ,__a_•tia �i4�=i.iL Oai� wr�L_ . - � _ . �i� Pfa�it r��bd !�z �; ���:�r� ��.r� /�� H8t11� P11v� _3 � �-� �.��6'� � n,S�t, ;�.;. � y� R, . > �naa Phan� ' ` � ' - �� ' ' � • J i4r F�i6�1Ei� iOf� ��{'�Rf� O� Cilil� O�ilNll _._ >-�C� ,-.-(� • V � J • . •_w / �� �� Dii+�c�oc�s 6o��i L.ot �i� �� Taw�tpc �/� ^ " E� �e�LJ:'L:=L?..c� Lot#' �_� � � `z p�perty (�er� ro�ad.tiem�m aa�d nucr�be�a�: s� /��r��� .a} Ptr��rd i�w and ��; a�r �+ctt ot the �Q c�t� 4> �f�d �.. � F�ds�n9 � 7'�pe a� ' Vyfdtl�.� Dbp�y -� b) Nurr�6lr Qt 8edroo�tt� I�mbar af �� a pe0ple bo b0 �,,,,_,.,_ c) ' 9a�emenk Y�s ;, No _ V1�1 ttwor�+ ba paar�ng in itte ba�tr�ani? • . d) �ps Df�po�wt Yos „r, A1r� _ . � �� li�t � 1'yp�e Arhrabe �-'��r�w �.. � e�dWit1$ �. Rudla_, �l ..,.., � _ . �'�Y �� adJ� pct�eKy�Y�o4 _ No _... ilYee� Fk�qe in�t� ��tian cn ft�3 a+"� pien. �� �s tl» peap�� tao�4iq p�y `y��}� �� �? Yaa _ i�o � ��+� . . � � �r.�►r o�� �rr�t � � � �r a� � r� �s w�uc�►n� . . 3� PlbDPERiY LQIE� AND ��118T 8E CLEARLY �, � 17-� �'ROPQB� LdOt`.A7'MC?t�1 al� A�., �'1'��;�� ��� UR t�►[i�. � Tl�E �."7'� 1M�i' � READILY A� �pR,�l EVAL.tU►TDON BY THE 1'�J�I.TH D�P�1R�f7�i SiJiF�. �� f�sd�t malo� appla�on bo the F��on C.a�nlY ��t tfor a�� foc 'Itts � Go h� ��i°�� ��Y• ��� tl� t!� � af tftl� �On are ttu�a �td � rrnondrnum ���� an the pn�p�r�. 1��der�d i� th4 s� ia a�benad ar tha intiended u�e ct�a�t��,, � p� � ...� ��rrvrM.-� ,� 1� LL�""—`—� , � o�,�,� _ •� ;2�•-�. ._ t�, P�D, reee.lart7llri S��T4C %4AIK IN��EC'f10N CNE��41S'Z' (Type ll - � Tax Map # A�� Parce! # 39� Systern Type (Table Va) �o. OwnedAppiicant Subdivision �'.nn+a Q, �re� AddresslLocation � Ser.lPhase i� Lot #/ O� �� . . Septic Tank n� a� � cat�on nes ni a ate . St�te ID/date -3� � _ � � - T�+ench Wid�th � ft. �- � Capa ' - p . gat. �,i Trenct�. Depth -�3c� in. ,� � • Tee and Flter ,� Trench Len S�� ft, Baffle ✓ Trench Grade � Sealar�t Trench S acin � Riser if a licable ✓ Rock De th and Qual' Tank Ou�et:Seai Dams/Ste owns etc. � . Permanerrt Marker Pressure Laterals � - Pump Tank � Hole Spacing . . . tate e ' � o e .. . . � � , . . � Ca city . . gal. Pi e Sieeve . � � - � � � � � Wate roof /Sealarrt � Tum-u sfProtectors � - � � � . � � . Riser � � �Required Seibacics Water Ti hf � Frnm Welis �. � ` � � � Pump- � From Property lines � . �hedc VaLveJGate Valve . � . . .Strvcturesl8asemerrts.:: � �.� . - ti-si on o e . . rt es ra�na � e. ays. . . . � Fioatsl�witct�es � : : . . . . . .: . �. � : . . �SurFace` Waters -. - - Alarm visable and audible Pubiic Water Su lies . Electrical Componer�ts Verticai Cuts �>2 ft . Rate m Water Unes Ap roved Pum Mode! Vehicle Traffic Blocic Under Pum Ad'acer�t�S ems � Pu Removal RopelChain Easemetrts/Ri � ht of 1Nays ' Distribution System � Other Serial Distribution ' �a�� Easements Recorded . ressure an o e e r ntract Low Pressure Pi e • Tri-Partate A reement Aoor. Pioe Material and Grade � Comments' pcf�d rev. 3J13/01 0 0 DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES DIVISION OF ENVIRONMENTAL HEALTH ON-SITE WASTEWATER SECTION Sheet / of� PROPERTY ID #: COUNTY:� ��IL/SITE EVALUATION for ON-�ITE WASTEWATER SYSTEM OWNER: �, �! APPLICATION DATE ADDRESS: � O DATE EVALUATED: ^3 �d PROPOSED FACILITY: PRO OSED DESIG FLOW (.1949): PROPERTY SiZE: LOCATION OF SITE: PROPERTY RECORDED: WATER SUPPLY: C�7'I�rivate ❑ Public C�Vell ❑ Spring ❑ Other r. .-. / r, _ DESCRIi'TION INITIAL SYSTEM � REPAIR SYSTEM OTHER FACTORS (.1946): s Available Space (.1945) S SITE CLASSIFICATION (.1948): s s EVALUATED BY: �� s'! . G� . System Type(s) � � � OTHER(S) PRESENT: I Site LTAR I �,'� I , COMMENTS: LEGEND use the following standard abbreviations SUIL CONVENTIONAL LPP MINERALOGY/ LANDSCAPE POSITION GROUP TE%TURE .1955 LTAR* .1957 LTAR* CONSISTENCE STRUCTURE CC (Concave Slope) CV (Convex Slope) D (Drainage Way) DS (Debris Slump) FP (Flood Plain) FS (Foot Slope) H (Head Slope) L (Linear Slope) N (Nose Slope) R (Ridge) S (Shoulder Slope) T (Terrace) I S (Sand) LS (Loamy 5and) II SL (Sandy Loam) L (Loant) III Si(Silt) SiCL (Silry Clay Loam) CL (Clay Loam) SCL (Sandy Clay Loam) SLC (Silt toam Clay) IV SC (Sandy Clay) SiC (Silty Clay) O (Orga-nic) 1.2 - 0.8 0.6 - 0.4 0.8-0.6 0.4-03 0.6-03 0.3-0.15 NEXP (Non�xpansive) G (Single Grain) SEXP (Slightly Expansive) M (Massive) EXP (Expansive) CR (Crumb) GR (Granular) SBK (Subangular Blocky) ADK (Angular Blocky) PL (Platy) PR (Prismatic) NiOIST V1'ET VFR (Very Friable) NS (Non-sficky) 0.4 - 0.1 0.2 - 0.05 FR (Friable) SS (Slightly Sticky) FI (Firtn) S (Sticky) VFI (Very Ficm v. Very Sticky) VS (Very Sticky) None EFI (Extremely Firm) NP (Non-plastic) SP (Slightly Plastic) *Adjust LTAR due to depth, consist�ce, stn�cture, soil wetness, landscape, position, wastewater flow and quality. P(P1asHc) NOTES VP (Very Plastic) HOItIZ�NDEPTH 1n inches below nahual soil surface DEPTIiOFFILL In inches from land surface RES7RICTIVE HORIZON Thickness and depth from land surface SAPROLITE S(suitable) oi U(unsuitable) SOIL WETNESS Inches from land surface to free «�ater or inches from land surface to soil colors with chroma 2 or less - record Munsell color chip designation CI.ASSIFICATION S(Suitable), PS (Provisionally Suitnble), or U(Unsuitable) Evaluation of saprolite shall be by pits. Long-term Acceptance Rate (LTAR): gaVday/ft • Show ornllle locations and other site features (dimensions. reference or benchmark. and North). DEHNR (######) � Review (#####) G' ` �-��� ; ���' ��1i�.�'�J' �� �—� ��� ��� I���-�a-� �.-..,,-„ ���.�.IL 1L� � �.IL�I�a. Applicant: Location: �r ,� . ; P�rBnit'�Ialad �or �ive Y��rs Type of Facility: # of Occupants � �3'' # of Be� Proposed Wastewater System: � Proposed Repair: Permit Conditions: x M�p � � � �rc : � S�ubdiv� 5ion /�• - . - � - � h:�s = Se�cfion� Lot # / � ��a�r���ffie�� �era�it l�To E�pira�aon ,%',:'�,.;.�-z ;l'� �.s; �j�����. ,, New �'Addition Vb�ate� Suppl� e> � i/ ooms � Projected Daily Flow �y� g.p.d. Owner or Legal Representative Signature: Authorized State Agent: Type: �� Type: ��� Date: �—(�– 6 `'! Date: % .$�Q3 The issuance of this peimit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements aze met. 'This Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `iaws and Rules for Sewage Treatment and Disposal Systems' (15A NCAC 1�A .1900). Neither Person County nor the Environmental I�ealth Specialist warrants that the septic tank system dvill continue to function §atisfactorily in the future or that the water supply will remain potable. L��$�i0�'9��$lOII $O �OHfl3$�'9�C� ��3$+2�8���' S�S$�ifl'� �Required for �uilding Pernait) * See site plan and additianal attachments (�. Proposed Wastewater System: (i'�n.�����-�a'�ncy.r Type ��. Wastewater Flow ��G� g.p.d. New � Repair Expansion Soil I�T�2: � 3 g.p.d./ ft 2 Type of Facility: �� ,s',�% -�'�-�.-, ` ,� ��, �,��,,e .� Basement Yes �-'No S�Jastewater 3ystem I2equireanent� Tank Size: Septic Tank: ' ct'r? gal Pa�p '�ank: -- gal Grease Trap: �— gal Drainfield: Total Area: % e��:s sq ft 'I'otal I.ength. � ft 10�Iaximuan'T�ench Dep4�a �O in �rench Wic�#� � �t P�aanuffi �oa� �over: 6' an I)ista�bution: ✓ Distribution Box Seria1 Distribution Minimum Trench Separation: � ft Pressure Manifold Specifications: � �� S; � ����.� � A�tho�nzed St�te Age�t: �� Permit Expiration Date: rs � 0 Date: - .5��- �3 The type of system permitted is � nventional Innovative Alternative. I accept the specifications of the permit. Owner/�.�g�l ��prPse�tative: � Date: �`� �.? ` � � . , PCHD 1/17/2003 ��� ?,�� 1L J.Le!��ls.J�J� . �--- _- �--r- � � ��� � .Z�sawnlr�aar�TM* �aa�.�.11. g'''��.m�.�� STTE PLAN ' l/� / a-�v ��e �t�s��,- �R�v �"•sr-S' Tax :�Iap # - Parcel # �� Subdivisi n a/,' r P Secuon/Lor# / 07 . �- s-c�3 Authorized State Agent Date System compoaeats represent approximate coQrorus only. The cnntraaormustilag the system prior to br 'b nni aD the tustaAation m insure that propergrade is maiatarned ' \ _ S�'�Q,y1�4 �P � - .�d -, � Ai �lccx ��/2P�S' 4��l � �'s ��� - ,��,o �s_ , � �� � � YELLI���-Q 5�' � ��! vE �/IN �� ��: / � /�� � . ��� � � - �' /� � \ / � � . � � ��� �S � � � ^� . , � JYQ7 � � ��»c L � 7�. � �' Scale• % �^ � 0 � � � . � � � . Cn � S s���, - �` ''� �S ) �� 7 ��j/1/v /„� �.� (s36 � w� p -box ° rn� ��30'' �'Iax. l���l, �� i rcxD, «v. o�/L/oi � ��� �� ���� �� �...�_ � ►. • � � �J � � � IE��.��mm � ���.Il IE���.]L� Applican� � ,...,.u..... ��� � ia�x (�1�;� �' F�:rc��i = • S'UfJC�:lb'F5'IOtI � a� �. � • / P�h:a,se Sec�tiora Lot r . . O�perat��n: Perrnit . � , System Type (In Accordance With Table Va): �c. � THIS . SYSTEM HAS BE�N IN�?ALLED � IN COMPLJANCE WITH APPLlCABLE NORTH ' CAROLtNi4 GENERAL STATUTES, RULES .FOF� .SEWAGE �:rREATMENT ANQ �DISPOSAL, � AND- ALL CONDITiONS OF T�IE IMPROVEMENT ' PERMIT . AND CQNSTRUCTION AUTHORIZiR . . � . . . . � . .... . � _ . � =��- '. � . .. Authorized tate �A nt � � � . . � _ � � � � : • Date • - � � � tnstailed By. f�' C�i- �1 . Date: %"D��'���� .. . . . . . � 'CHD, rev. 07l29/OZ , \��� J � �� t � 1'L.L! �%s V.. �! �� v. � � � � ����� �' �n�as�¢��aa�cn.�m�.�.� ��ca�.���. w�' �� ��' �� ���E ��� 1�'3"�'�iC�3�D �Y..�l�d F�� WEi.I. SI�'E ����J'�' '�'ax 1@�ap #: .-^�' '"r � Parc�i # 3 � � 7Cawn��ip �%. �� e1�'�P:�^ Applicant e Saabdijrisnon: ��r� i^►'cf�� �°r't�� Se�tio�: I.�t: l D 7 L�ca�ion: 0 �e of'�ater Sa�����r. �Individual Commu�.itp Public Re�uire�ae�t�• Site Approved bp ✓ CS `�-aco-�-Q Grouting Approved bp �/ CS `�- a�-zs� Well Log ✓ GS 7-a�- c�l Well T Air Vent � - o� Hos� Bib � Concrete Slab � We� Daalfler. fv�.�1e V.�e� b��1b�.� `�Z�- CS , a-z.s-� v Well A.pgaw�ed �See A��ses� 5ite Sketc.�a� Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from anp building founda�ion. Other conditi r, � PC�-ID, rev. 09/07/01 �� :s I�II�I�:� ��T �� oo � �z � � ��--- f .o � � - ������-: ���ns�����.��:a ���.���. D�o Dr�Olk�Csl 7 � a3 -��' � /J ('� Grout Log Owner: /�-r 1� Tax Map� Parcel #�� �7 Location: Subdivision: Ch- � � Lot # �3 ? Well Constrnction Distance From nearest Property Line (Minimum 10 feet) C� Distance from Septic System (Minimum 60 feet) Total Depth: �_ ft Yield: �� GPM Static Water Level: n� 5, ft Water Bearing Zones: Depth �/ G ft�ft ft ft Casing: Depth: From � to � ft. Diameter: �_ in Type: Galvanized Steel � Weight: Thiclrness: �� Height above Ground: � in Drive Shoe: ,/� Yes No Any problems encountered while setting casing� Yes � No If "yes" give reason: Grout: � Neat: Sand/Cement Concrete GraveUCement / . Annular Space Width inches Water in Annular Space Yes No Method of Grout: Pumped Pressure Poured _� Depth �_ to �_ Ft. Materials Used: � No. Bags Portland cement �d V�� Weight of 1 Bag 5� Pounds If mixture (sand, gravel, cuttings — Ratio 2— to �. ID plates: �es _ No 4 x 4 slab ! Yes _ No Liner: Depth: Date Installed: Grout: Installed by: _ Drilling Log Location Drawing ��� � � ��. �� ��� !� _ � - • -� -- � .�� i_ / i � • %� � ��� � �`�� .� �_ • �1�� � . _� � . .� � ���� 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 He epartment. �� � Signature of Con�ctor�_�� g���G� v ti� ID#� Date 7'�3 �� Pump Installment Pump Installation Contractor: � �� State Registrarion Number: � �.¢ �� Pump Depth: <« ft �tatic/ Water Level: 2� ft Pump Make & Model: a � c K�2� Pump Size and Rating: __ ��� hp �Q 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 th'�cn� s been pr 'ded to the well owner. . Pump Installer S' S._C_,�t �C� Date: �� `CT � PCHD rev O1/27/04 ,