A40 401�v
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��lication Date: -c�l�.-olp 1�12 t 3'►S ��� Tax Maa #:
Amount Paid: . � /
Receipt #: ��U-Q� ParcEl #: � ° 1
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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
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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
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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,�_
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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� • � � - . : _
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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..
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Section/Lo�'# 111
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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
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A�plicant Aw i
Locaiaon: t 'r
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� 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�
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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(� �
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. 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 �.� �
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Ott�or canditi,o�s' . .
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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 ��
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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