A40 402��lication Date: �''�"� 6
Amount Paid• �0��
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Tax MaQ #: � � �
Parcal #: Lf o a
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APPLICATION FaR SERVICES
�
1) Penr�it requested by: (Ownedagerrt/prospective owner): ��~�
Home Phone: � 3�S� - a s'6"�— Address;;� s-� ss ' �-
Business Phone: ,.!'4Y a l� � �re�,�.:� h c. a� s� s� �
2) Name and address of currer�t owne� �
3) Property Description: Lot size: _�_ Township: �_ Su
Directions to the propefty �Including rc�ad names and numbers): ��
Lot # I la
1515 �� on I{uf� -�I � or Wi l�0ak�---7 � on Quac�wrqa�G --� (� on YeU�r►g{an
4) proposed Use and Structure Description: answer e of the foJl wing questi�dns:
.... a) Proposed ✓, Existing . Type af Structure: ��e � Width: �� pepth: z�
��' b) Nuinber of Bedrooms: �� Number of occupants or peopie to 6e served: �
��� c) Basemer� Yes .�No ��II there be plumbing in the basement?
. d) 6arbage Oisposal: Yes . No J
5) Water Suppiy Type: Private !� (new _ or existing�. Public� Community . Spring _
Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate Iocatlon on the
'site plan.
6) Does your property car�taln previously identifled ju�isdtctional wetlands? Yes_ No �
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SiTE PLAN MUST BE SUBMITTED WtTH THIS APPLICATION.
➢ PROPERTY UNES AND CORNERS MUST BE Ct.EARLY MARI�D. -,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STA�D OR FLAGGED.
➢ THE SITE MUS'� 6E RF�IDILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
STAFF. � �
I hereby make appiication.to the. Person County Health Department for a site evaluation for the on-site s�+vage disposal
system for the above-described property. 1 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
hecome invali�l.
c��
Legal Representative
1l ° � ' �
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PCHD, rev. OBI27102
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Su�bdivision �- ; , . � ; . -
Fh��se�Sect�iom:'Lot �
Improvement �ermit
Parmit Valid %r ive Years I�To �apira4ion �
Type of Facility: New ✓Addition i�Vater 5upply ��
# of Occupants # of Bedrooms 3 Projected Daily Flow �_ g.p.d.
Proposed Wastewater System: 'o � Type: �q
Proposed Repair: e 'Z o a Type:
►� r � ,���
Permit C�}ditions: , a�' i [0 �re►►� O,r��;���_%D n.v�. �►�r'ldi,,q „a%a�ia S 9�
Owner or Legal ]
Authorized State
Date: �' �S-ob
Date: .r /S �(�
. �
The issuance of this permit by the Health Department in does not guarantee the issuance of other petmits. If 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;'pTa�t'�or the intended use changes. The Improvement Permit is not
ai'fected by a change in ownership of the property. This permit was issued in complianca with the provisions of the North Carolina
`Laws and Rules for Sewa�e Treatment and IDisposal Svstems' (15A NCAC 18A .1900). Neither Person �ounty nor` the. ::
Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that
the water supply will remain potable. �
Autlaorization to Construct Wastev�ater System (Required for Building Permit)
* See site plan and additional attachments (_). .
Proposed tewater System:�v �lOna � Type � Wastewater Flow �g.p.d.
New �Repair Expansion _ � SQiI I.TA�:2: . 27 g.p.d./ ft 2
Type of Facility: ri✓a�2 /PP�r�e.rlG� Basement _ Ye-�
�astevvater Systeffi Requireu�ents
Tank Size: Septic 'Tank: 400 gai Pu�►p Tank: �—gal Grease Trap: --�
Drainfield: Total Area: � sq ft Total I,ength y3(,Q it 1VIa�ffium Trench Deptli-/ 8�--- �an �
" Qp.0
'Trench Width � ft 1Viinimnm Soil Cover: _� in 1Vlini�um Trench Separation: 7 it
Iiist�-ibution: V I)istribution �oz Serial Distribution Pressure 10�1anifold
Specifications: �o /�'F /%1S1A1� ir� w� ��n��7c�.Lt -
Authorized State Agents
Permit Exui
The type of system permitted is
permi,t.
Owne�/Legal �t�p�esEntative:
Date: ,�=.
�nventional
��5�.,
Accepted
Date: � /.� O(o
Alternative. I accept the specifications of the
Date: b `3- fl �a
PCFID rev. 11/10lOS-
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Sub ' ' ion a � Se�on,/Lot#_112
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, Authorized S�tate Agent . • Date �
`� Systenr com�ionen�r re�firesent a�mxisnate�conto�rs only. The contruc#ar 9rar�rtfYcrg tlae systern prior to
be nnin the installatzon to insur�e that ro er ss maantazned --- __ _
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Subcilivision �� � � / _ .
Fh�.se Sect.ion:Lot #
# of Bed'�rooms
Applicant: �5�.�,��.� �,>,��.r{/s �
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Location: �
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System Type (in Accordance With Table Va): �
THIS SYSTEM HAS BEEN INSTALLED IM COMPLIANCE WITH APPLICABLE NORTH
CAROLIi�lA GEidERAL STATUTES, RULES FOR SEWAGE TREATMEAIT AND DISPOSAL,
AIdD ALL CONDITIONS OF "� THE tMPROVEMEiVT PERiVI1T AfVD CQNSTRUCTION
AUTHORIZATION. �
Authoriz St e Agent
Installed By:�/�,:�,�.� � �n�
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Date � �
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Tax Map #��_ Pares! #�D �_ Sysitem Type (Table Va)
Owner/Applicant Subdivision ��a� ,�✓io�r + �� �
Address/Location Se�fPhase Lot # ir z
Se tic Tank nat�� a� itr� �cai�on ene� n��a ate
State�ID/date� 5��� g�i Trench Width �" � ft. �/i
Ca ac' al. � � Trench De tt� / in.
Tee and Fiiter � Trencli Len th U ft.
Baffie � Trench Grade � � �
Sealant Trenct� S acin �
Riser ifi a licable � � Rock De th and Qual'
Tank Outlet Seal Dams/Ste downs etc. �
Permanent Marker - Pressure Laterals �
Pumu Tank Hole Soacina �
/Sealant
Riser
Water Tight
� Pump
Checic ValvelGate Valve
and aud
� Rate m �
A roved Pump Model
Blocic Under Pum
Pum Removal Ro e/Chain
. ��Distribuiivn. System
� Serial Distribution
ressure ani o
Low Fressure Pi e
A r. Pi e 1�lateriai and Grade
Valv�s
Sleeve
Required� Setbacks
From Welis �
From Praperty lines
StructuresBasements
es rainage ay:
Surface Waters
Public Water Supplies
Vertical Cuts (>2 ft-)
Wa#er Lines
Ve�icle�Traffic �
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Other
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e e era or
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Aug 15 06 02:41 p Keith L. Barnette
336-598-9275 p.1
. . . �. o�� oo � 3z� 7
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_. . �(i 1�'ri�10 r� �i-hC � 1� y�
: . .: C� {�:.����...
���R���.�..��.���:�: ���.�.�� D�o Dr��U�1 � iS�-o 6 .
�1 Groat Log
Owner: �G4 ���f r�'� �' n S Tax Map �l � Parcel # �! D�-
Location:
Subdivision: �c ', Lot # ��_
� Well Constractioa ;
Distance From neazest Property Line (Minimum 14 feet) l� �- �'� �
Distance from Septic System �Minunum 60 feet) f�
Total Depth: 1 �, n ft Yie1d: Z n GPM � Static Water I.evel: 7 S� ft �uC).�5t n
Water Bearing Zones: Depth <<l �� ft ft ft ft �
Casing: " •
Depth: From .�% to 1� L� ft. I?iameter. ����L in
Type: Galvanized Stee! _�
Weigh� Thic[a�ess: �(!�. Height above Ground: i.Z- in ,
Drive Shoe: � Yes Na Any problems encountered while setting casing� Yes �No
If "yes" give reason_ T
Grout: " � /
- Nea� SandlCemen# Cancrete GraveUCement �/
. ��. Annular Space Width � inches Water in Ann Space �es � Na
Method of Grou� Pumped Pressure Poured � Depth to Ft.
MateriaLs Used:
�%. Bags Portland cement � Weight of 1 Bag �/� Pounds
if mixture (sand, gravel, cuttings) — Ratio to
ID plates: t-�Yes _ No 4 x 4 slab �_ No
Liner:
Degth:
.. ,.�
Date Instatled: Grout
Drilling Log
Installed by: �
Lacation �rawing
Fram To For�nation r � '
a �.erhu� �� � ��.��F �
f �n sa�� s � �
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I hereby certify ihat the above infarma.tion is cozrect and that this well was constructed in accardance with re�tlations set forth.
by the Person County Heaith Departimeri� '
Signature of CoMracior ../✓ � ID# � Z6 7 Date l-��'r 5'�� _
Pump InstallmenE
Purnp Installation Contractor. [�V�nG ��2 1N� l Z al� I�•'� � nL State Registration Number. � 2 G 7
PuYn�p Depth: � ft Static Water Level; �� ft
Pamp Make & Model: 1 r, �ac�c'��� Pump Size and Rating. �%2 hP r bP�
I hereby certify that this pump was instatled and the well head completed according to the Persan County Well Rules in effect
on ttris date and that a copy of this record has been provided to the well owner. _
Pump Installer Signatu�re ��� " � Da�te: a^ f�~�'� PCfID rev 01I27/04