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A40 401�v � �J� ��b ��lication Date: -c�l�.-olp 1�12 t 3'►S ��� Tax Maa #: Amount Paid: . � / Receipt #: ��U-Q� ParcEl #: � ° 1 � -� ,,��� .��� S� I�'I�I�� �� - - : � ������- 1Caa�.aa-oaa�-TM� .�aa�mll IE�om71�IEa APPLICATION FOR SERVICES �.,oT ) I 1 IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFiEfl, CHANGED, OR THE SITE IS ALTERED, THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. � 1) Permit requested by: (Owner/agent/prospective owner): !Y � Home Phone: 3 � �f �-�6 �— Address: s� � � �€� Business Phone: 3�� ���� �— C• � j 2) Name and address of current owne�: J g �n r - 3) Property Description: Lot size: �2�. Township: -f- � Directions to the property (Including road�n�t es an numbers): _ / �� .�"i� CU �'L d � 1`.r�.P �4 d4 ` �� Lot # / / 4) F�roposed Use and Structure Description: answer each of the followin questions: � a) Proposed ✓ Existing , Type of Structure: yi'1 6� �o,� Width: S� Depth: �8r b) Number of Bedrooms: �_ Number of occupants or eople to be served: c) Basement: Yes , No ✓ Will there be plumbing in the basement? d) Garbage Disposal: Yes No � 5) 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 jurisdictionai wetlands? Yes_ No � PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY L1NES AND CORNERS MUST BE CLEARLY MARKED. � ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAI(ED OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBL� 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, n Owner or F�e,g�l Representative g��-�--d� Date PCND, rev. 06/27/02 .. l�-... .t2a.•s.i • p17�3�7�03 . . �� . � 117 -' w _ M � s,.� ' �' ;.� a �� �� :rri � ;Q � � tC p � :- m z z c� � � � '' ; ` 'p� � \ �1 248.33' � _._. ; � . w t'' � • � '�' a � � � � - cb t ; \� ,.,M�, � i �, o � : � � � s' ^ � Lp 111 �� � �z 1.00 ACRES �: � � `'L z ; `� _ � � � �� _ �.; ., � a G �' � � � � :;::::S82'42:'�1."..E 4"" " w 1 250.0�' .- ... ._. --� �- ' � � ...:: _. � � '� � �� _ , ; 't uF,�i it � W . , � ? Z � n : , � p CO � M �� -� —� � � . I� �T ��� � �, t� i� - 1.00 ACRES .y'`�. � W '� ' d �^ co :-. a �. Z` o� rn � ._ � ; "� i�o ry � o � co n � � :•:-S&5'57-'57"..E��. ,...:: <,..�t..., a� z � 25206' i3 �_ LpT 109 r 1.OQ ACRES cn ti co t�l � . : �-yY yy� :+ �6j �9�• f LOi' 108 } 7.fl(3 ACRES LOT 103 t,Ofl ACRES 283.54' �DT 1�74 1.00 ACRES LOT 105 1.OQ ACRFS 2$0.53' LOT 1 C?6 q.00 ACRES LOT 707 1.00 ACRES � a� � � � � -- �. "' N8��8'19`yy L7 �d2_ 87' N$2'S8'19'yy L6 .. '' '�a..... , -�.. ...M�� ]fi3.�. ;_ ,,, �""'..,*„�,,,,�„ -----------�-�.1...._� �J���...+�.w.'��7f�.r. ��isi.it•,�: �'�'� ;'f�t:: �il•� ����� Ii�:VC�' D�2tC ili%J�. . � �, t:� '1':i•. ', ' u�.E�i .. ,.:i�v:�.LL.4�l'J�{�L'i O�CS.L il'si � � ��� �� � �.131i 1= �1.� �.� �.. . �p .. .. �,� >+J � � � ���� � 1��.�-a.��m„-„ -n-n-n <���.�.]1 IE-3L�.�,,II�I�. Applicant: Location: P�rmit Valid %r ive Ye Type ofFacility: riv l� # of Occupants �_ # of Proposed Wastewat System: Proposed Repair: �� �. T�x fNa�� i� � � �rcel � I / � S�u.bti�i�visiori , _ ,,.� � Ph�s�e,Se.ct+ian.'Lot � —7 ][nnprovement �'ermit No �zpiration �� New -,/Addition VVater Snpply J{�/�// s Projected Daily Flow �_ g.p.d. � � Type: JL g� Type: ,11L,�_ `1 •- n � . �.� � � , �?tYl:7/�'�'. ! . Owner or Legal Represe Authorized State Agent: Date: /o�� -c� Date: �' Z8-�O(o . � The issuance of this permit by the Health Department in does nat 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;pl'�it''or the intended use changes. The Improvement Permit is no# a�ected liy a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina, : `Laws and Rules fnr Sewa�e Treatment and Disuosal Svstems' (15A NCAC 18A .1900). Neither Person �oun#y�: por'"the.'` = Environmental Health 5pecialist warrants that the septic tank system will continue to function satisfactorily in the futnre or thaf. the water supply will remain potable. • � Authorization to Construct'Wastewater System (itequired for Building Permit) * See site plan and additional attachments (_). � Proposed W/� ewater System: C,OnvP Q»a / Tjrpe � Wastewater Flow �Q �.p.d. New l/ Rep�}'�� Exp .�on � � Soil LTA�i: -.� g.p.dJ ft 2 Type of Facility: I'r; �,r� �Q�� � Basement _ Yes �No . �Vastewate� System Req�rements 'Tank Size: Septic'Tank:� DD gal Pnmp Tank:'� gal Grease Trap: � gal I)rai.nfield: Total Area: 20p sq ft Total Length �4�% ft � 11�a�muiu Trench Depth 2D in � � /)D�C. Trench Width � ft lYiinimnm Soil Cover�-..�_ in Minimum Trench Separation: _�_ ft Iiist�ibution: Y�istribution �oz �nal �Distribution Pressure 10�I.wifold . Specifications: �4rc�li�n o�ur- � �i''o�tG�i d�o� • � � - . : _ �7 � � / -- Eiutlaorized State A,€ Permit 'The type of system pennitted is permit. Ow�et/�egal �tEpres�ntatave: Accepted � �� Date: Alternative. I accept the specifications of the Date: f0 - Z-o(, ' PCHD rev. l l/10/QS.. , b .�.,���+J� ���� �d., � • . � � 'L.� � �LJ l�l �� IEza-oaa-o� �- em�.l :�-]C�al� ,..- ���,� � . . . . ►.. •, . . /���.. ,.- � � �... . .. :.�� r��■ -• � ' �•� �� :/� ■ Tag Map #��iU . P�rce1 # �Q% Section/Lo�'# 111 - 8- 2�'-D(Q . Date Systes� cumponess�a� r�,r�sent appr�axs�ts�cvn�ours only: The �r m�st, flag the syste�n prior to bsgiraung tlu t�rstaAation �v =�surg that pmpergsrtde r:s �nainta�ed - �, ..' -- � .-W- --- - - .- � ., �va�•� �'��u� � _. �. :.,; .. . �b• 1�' �n�fiAl �i�S-�QIYI ���, �-`� _ — — b � a1� .� 3 b�d. ��� �`/ 3�.� l �� P ��.� -� t�p�r Convevrhdnov� �, �b ,. ��h �:. � ,;. ,o bo-�w� ui ' Secl'0. � ��� � ia; -- — � `i� . � � r �#,w � :; � � „_5�� Scac�� � � a`��- �� � �k� 6 10� , � __� - go� I �°° Po,` � P-reA � i� I �_ �1 � �!� ��� 1 �,07� ......._.,���,.._::: �:�.,�_'Q �� .� . � �� ��� n ' G keV� 5� �� � .� �,�,�� ► o� - . y , . . : ,.� ��-,. . . .. .. ;�.7�.�� �-y,�. -��� �� ;� �. .. / y � � �P� ---.,... � e�t V �'43, �� n� �J ��.t��r' !�� � : �.,�,� �� ��.� i_�' � ? ��� _ �,S 1 ,�^� � ' � �J `V �� 1 ��T . � �_N'�Z� �'n'y '*'Tm <L �. ��i.� � � a2l.�i�ICl. A�plicant Aw i Locaiaon: t 'r _ . /� _.. �., � /� • _ ,. � . _ f _ '� n N _ R � . L 8 �� x .' � � � a,rc � subdiv�f�.ic�n 1►� . : . e • � . i cl �. Ei --t16) fl; O cr Q.• 2'ffll' O � FTi15 ' ������� �� • �� . . . � � System Type (in Acr,�rda��: W�ih Ta�ie Va): � �Z� 'T�-i1S SYSTEi�i i�1S �3E��i il\iST.ALLE� 1�i Ct)[90iPL.iAIdC� Wii�i AP.QlaCABi.E NORT}-f G�►ROL• I%s�, GEiVEi�AL. STA7VTE�, Rt3i.�S Ft)R S�►ilA�� TREAT3�i1E�'�T AAID DIS�OSAL, �1MD AL• i. �al�lDITI�NS • OF ` THE iMP�flVE31dEi�T PE�IT ,�,N� Ct)f4i5TRllGT10� . ai rr�in�o'nc��_ _ . • . / �_-�/ `�X� - _ Daie � oaie: �"a —1/—aCe � ' � ���� ��'�� �I`��s��� '� '�d :���� � ��� �� - �'� T� P�1a� �� Parc..� # � System Typ� (i�le Va) . FZ Qwne�1?,pplic�# � Subdivis�on a K . . Addi���cation Se�Pf�as� L� � 1 t(� � �I � �c�d re�r. J't::JO�i s 0 � � • • : . : � . ' a"s'4' ,i':? s . r' ,,,n "" ;� i ' • _ �. r•�w.�^;+�r ', _ ,r i : .. � r�. sic'. .y+ • �r �•,x ::'�� t ,~ . � . , � ' ._� j�. ' . �'i, • . . w• �•�y�.. .. ....r�.�i s 7��� • . : � '� . • � �� • � . • • • . � � �� � �� `7 ��G:71.i�.i � �� , � ' . . . a • Ta�c�SQ i� P81Cr� # � � �OWil6hiQ: � • � . �'�li'ca� , a . La� # . • Sui�ivisi�o�; a�t . / � 1 _ �� ,� _ �,i _ � � . , � -�` . „ _.� . �' , �. . :. • • 1`y�ri o��{ia�r �� = ._ �Y �� . . , . , $e � . ' �� - . ., 9rt� A}�ovod gy; � b 2.� c�o ' Lino� � . . •. � �g�cdBYY � � ' 7�aIlodby: . � . . We11 Lc� ' � . ' Dqrth eafi � � . . pnmP Ta�. -, C3�+a�d: . . � � . Wall Tap� . . De�e: � • - ` . Air V� � ' • • � � � ; Hoeo Biix • . . . �D'a�r 3�pla . ' - � �S� � . � . C',a�cmete �lab: • • . ' . - Wdl Dr�I�; .. . _ � Woll ApQtrovo�by: Det�. . . . �ee �i�htr.l�� 9� 9lrete�'�''�'E't • . ' Wdle m�ist be 10 fr.at fiiom pcopa�ty }ine�. ' • ' � Wolls muet ba lU0 �$�ao� �oQtic sj�e�. . . • Wells amet�tio at_1eaet 25 feet�from aay l�dtiug �.� � � � , . . Ott�or canditi,o�s' . . � . • . • . � • . }� " rev 0112'f104 � ` ` �f I�'I -��$.� ���T � ao � z y � � ��� `..�.�--� ' c� � ��T��Y '� �ao 1��.��v�� c�� � . _ ���n���:;::;r,, ��.�.�:� ���.�.�� o� o� iQ �� a� Owner: Location: Subdivision: Grout Log Tax IVIap � Parcel # �� Lot # . - Well Constraction Distance From nearest Property Line (Minimum 10 feet) t% Distance from Septic System (Minimum 6.0 feet) Total Depth: � Lv ft Yield: � GPM � Static Water Level: Z, d ft Water Bearing Zones: Depth � ft �D � ft /S ft ft Casing: Depth: From _� to �� ft. Diameter: � in 'I�pe: Galvanized Steel _� Weigh� Thiclrness: �Q Q Height above Ground: in Drive Shoe: � Yes No Any problems encountered while setting casing? Yes �6 If "yes" give reason: Grout: " Neat: Sand/Cement Z� 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 � Weight of 1 Bag Pounds If mixture (sand, gravel, cuttings) — Ratio to ID plates: _ Yes _ No 4 x 4 slab _ Yes _ No Liner: _ ,,, � Depth: Date Installed: Grout: Installed by: _ Drilling Log Location Drawing From To Formation �� � �� � �� r v � � , . �4�� . �- �lG 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 D artme t. ' Signature of Contractor ID# 2. �t Date �l� l7 D� _ Pnmp Installment Pump Installation Contractor: / ) �7+ �l c!i LY �V `e [ � State Registration Number: 2 % ` / Pump Depth: �i ft Static Water Level: �('�_ ft Pump Make & Model: Pump Size and Rating: �hp �� gpm I hereby certify that this pump was installed and the well head completed accord'mg to the Person County Well Rules in effeet on this date and that a capy of ttus r rd has b provided to the well owner. . Pump Installer Signature Date: � PCHD rev O1/27/04