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A40 402��lication Date: �''�"� 6 Amount Paid• �0�� Receiat #• �� d � 1�.°�� � g_ � o ( ��-����°� l � � Tax MaQ #: � � � Parcal #: Lf o a ���_ � ���.� �� - _ � � � �T1QT��` ��.�a-��.,.-,.-� .e��.m.a ���.a.,��. 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 ° � ' � �"S c PCHD, rev. OBI27102 ��� J �� 1 � / d IR �� L1J V .�5;;� : . ': . . � �=�� � � ��T�°� �a'II.�'717�cmn�.�^�'T c�7t��.�a.� ��a�.�'[�� T�x Ma�� � / ' �rc�el � � 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- , � •�.���' �� �1L:1��`V� �. •��.�a �- � � �OO ��.7�'I�� � �.���,� „�.� ,e��.m.� �,��,�. . _ . s��. s��.���; � -- Nam.e n. Tag Map #��,�Q_Pa.�cel #�2 . Sub ' ' ion a � Se�on,/Lot#_112 , . S� ��� � s , 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 --- __ _ -- - ----� __�'_ __...__ ....._ _ _ _ � -.-----.___�-�'---�e-�--------_ __ _____ ' S s+�erv, J.,_, n i{�a � - 3�0 . . � 3 6�� — 34� C nYe►�h'oha�� . 2?� �� � ( ; � —1g " ��� d��� ; . . , � r,;Q► b��,bufia,� ��i�}�'''� �'��� �i� 1 j�t�o IUv;f' r'nsfa!( t i� , „`��y.::.. . _ �: ��+ �6Nd��,o� '..i^.: ul, :t.� � 1s-'L+�...is+1;:d.�:;t;p.t , • � � ^� I �)ul����' v /��Q Y n ` I v i 1°° v W�� �\ \ � ,:.� .: ,,, o� �- _ _ � } ���. . .���-�� . . � � �. { � '� � �.• �' � � � , � �' a "� �) f� , � `��Ci r��'�.J� y� j! , t �, �� '1 � + �.. � � ' ��V���t � � � .C/`r • •—� , �����0�. `.��f�� ���� `�� �_.- ' � � � ���� ��av�n�-��as�t��ss��n.� �`���.���n. �x M�p � � � P�rcel # �i Subcilivision �� � � / _ . Fh�.se Sect.ion:Lot # # of Bed'�rooms Applicant: �5�.�,��.� �,>,��.r{/s � v Location: � � '��, : �. ' , , • ; �� .' 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� � � ���� . Date � � Date: . �� ���� V � .. ly' % — d'--� ,�, �5-�ooa STd -��z ,S'l� -dG � � i�" r�� ���� ��s � �� �„�s � „o J PCHD, rev. 07129/Q4 �E��'1C TANaC IR��P���'i0� ��E��fL9�i (%e 19 - f1l� 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 � � �EasementslRi ht: of Other . Easements Recorde e e era or . 7ri-Partate A reeme . Comments . . -, . pct�d rev. 3/13/Q�1 � 0 � • ' ' ' O ��� � � � �' ���. ����� ' � _ � � �. � � ��� � • yy� ' P� . � �� . � ��.. �. �� . � ... � � � � � ' �g� � ' �`� �� . � . ��e �, &� .. � � �' � �. ��� � � � � � � � � � °� • . �� , + � � ' . T � �� � � . l � � . � � 1 : � �. � � �� . �, . � . � �� � l �. . . . � � . �.� � - � � . � . � � • . � . . � . . . ••r • • ' • � � � < � 0 Aug 15 06 02:41 p Keith L. Barnette 336-598-9275 p.1 . . . �. o�� oo � 3z� 7 ��� )��� �����"�_ ✓G��i r-i �1•'� r�l[ _. . �(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 � � ! o , � � j cx/.— � � tSi� (i�s [C _ � (��J� 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