A40 405,�o�iication i3atE: `� _"" ��
Amount Aaid: O�-�
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A�PLICATION FOR SERVIC�S
Tax �liap �: � �O
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I� TFIE IM�OF2iVlAT10PI 1N i'�IE APPLICATION �O}i AFI IMPROVEMENT PERiV11T tS IiVCORRECT. FALSIFiED,
CHANGED OR THE SITE IS ALTERfED THEN THE IMi�OVEMEPIT PEF�MIT AND AUTH06alZ�'+T101V TO
CONSTF2UCT SH�►L� BECOME If�VALID.
1) Permi� requestec! by: Owrne lagentlprospective owner • �: � �� `�
Home Phone: 3 3/� -S/ry- //�3S Address: �����s ��, T1� �v �^ �hS'>3
Business Phone: .
2) Wame anc� address.of.caa�e�nt owner: ,$.:n, c
Co��Fu c 'F'
Col(��
T,��y
�o c(r►.i'
�oP ,�rK �S t�
S�3 -3a'Jl
;) Properly Descciptio�: Lot size: �'3�1 nr• Township: Flaf ' rl Subdivision: Lot #_j�
Directions to the prop�eety (Including road names and numbers): 7a�f� /l, (' /S ? � c n� s s f� �
�. � . . . . , n � _ _— ; �n� �'— .i►'
�cnf�l you se�u brcw�- �-wl,�+e i-i^a;ler o� I`���� a-I.e naX� Ka�o� I`l�;,f ;S f�c /s�.
�} Proposec9 Use and Stra�cture Description: answer each of the following questions:
a) Proposed ✓ F,cisting , Type of Structure:�� �,.� `� � m�b � le h�,,�_ Width: 1y . Depth:�—
b) Number of Bedrooms: _� Number of occup ts or people�to be served: _,�
c) Basement: Yes , No �Will there be plumbing in the basement? ------
d) Garbage Disposal: Yes . No �
5) Vllat�r Supply Ty�se: Private �new _ or existing�, Pub(ic , Community , Spring _
. � Are any wells on adjoining property? Yes ✓No _ If yes, please indicate a�proximate location on the
- si#e plan.
8) Does your property contain previously ideniifiect jurisciictionai wetlancls? Yes_, Ido, �
PLEASE NOTE THE �OLLOWING:
➢ A PL.AT OF THE PROPERTY OR SITE PL� MUST SE SUBMI'('TED WI?i-� TF16S APPLICA'F10P1.
➢� PROPERTY L1IdES AND CORNEl�S MUST BE CLEARLY MAR6C�D.
9 TNE Pli�P�SED LOCATION OF ALL STRUCTURES MUST BE ST�4�CED OR FLAGGED.
➢'�FiE SiTE MUST �E �DILY �►CCESSIBLE FOR .¢1N EVALU�►TION BY'THE Fi�LTH DEPARTMENT
STAFF.
I hereby make application to the Person County Health Depa�tment for a site evaluation for the on-site sewage disposal
system for.the above-described property. I agres that the contents�of this appfication are true and represent the maximum
faciiities to be placed on the propert,r. I understand if the site is altered or the interided use changes, ttie permit shall
become invalid. .
Owner or
Representative
$- c� -a 7
Date
. PCHD, rev. 06127/02
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S�uib�divis�ion s y o -
Ph:�,s� 'Se �tioia' at # �
Applicant: I�.�I�t.i �. �DV'�e :
Location: ►1 , � � . , � � � A . ,� . � /�
Permit Valici for � Fave YE
Type of Facility: �
# of Occupants �- # o
Proposed Wastewater System:
Proposed Repair: C.e,� ✓Qvv '
�nppoveffie�t Per�it
I�To Egpiration
New xAddition
s Projected Daily Flow � �
Permit Conditions: 5�� �jl t� � ��,rc��i� "
Owner or Legal
Authorized State
�ater Supply ��
g.p.d. �
Type: �?
Type:
Date:
Date: '7� 0`3
The issuance of this permit by the Health Deparhnent in does not 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 T1us
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 `Laws and
Rules or Sewage Treatment and Disposal Svstems' (15A NCAC 1�A .1900). Neither Person County nor the �nvironmental �ealth
Specialist warrants that the septic tank system. will continue to function satisfactorily in the future or that the water supply will remain
potabie. �
Author�a�aon to Cons�uct Wasiewater Systeyn �Itequired for �uilcling Permit)
* See site plan and additional attachments (_).
Proposed Wastewater System: V�'ti�w��tilQ r Typ�°r Wastewater Flow �6� g.p.d.
New �. Repair Expansion D 5oi1 L'TAIt: ►� g.p.d./ ft 2
Type of Facility: ��� 7��. Basement Yes hC No
Wa�iewater System Requirexments
Tank Size: Septic Tank: l�� gal Puanp Tank: gal Grease Trap: ga1
Drainfield: Total Area: i24� .sq ft Tota1 I,ength �� it lYla�mum Trench 1)epth ��{ in
�'rench dVidth � ft 16�ini�aum Soil Cover: � aaa Mini.mum Trench Separation: � ft�! '�•
Distrabution:
Specaficataons:
Distribution Box
� c
e s��=��
Autiao�.zed State Agent: ,/�i��
Permit Expiration Date:
�-Seria1 Distribution
�-P Y�
The type of system permitted is � Conventional
the permit.
i�wner/�e ;�1 x4e�r��entatave:
Pressure Manifold
Date: �—a��3
Innovative Alternative. I ac�ept the specifications of
Date:
PCHD 1/17/2003
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Applicanfi � �'�''� �
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�x fV1:��p a' • � �.r�c��l �
Subci;i��ris�ion r•
a ;- I
' t1:c.�rS �� E.? ^�I O til: 1.00 t.r
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� � � System Type (tn Acxordarice With `Tabte Va): . -
THIS� SYSTE�II E�4S� ��F� t(�ST�4LLE� d�f Ci3i�flP�1,�►P10E.'�YITH APPLiCABLE NOR7'�i
CM����P1 67G7iGi�M7.. �71t'1���Sy -����7 ��� ��iV7MV� fI6G1°�I IY'�Gitl 1 Pii7� ������P'!Ly •
�o a�.�. co�tD��o�s ..oF -rH� i�Pt�o����T� ���z �u. �coc�s-�vc�c�� �
�Au�r�to�-rt �u.. , � � � � : . � ..�.. .: � - : �
� c�� . : � � - ' - � �� 1 �� �' . . . . .:
. � �Authorized State Agent ' . � . . . � . ' . .- '� _ � � Date . :
�.�. � � �l�,eJ � � �- l'C,�3 .
Installed 8>>: I� ' . 1: Date: - '.
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���� �' � �����`�t�� �i��:�S�' �'�� �! � l� .
Ta,: N1a�a � � �arc�! � �� � System Type (T�le 1�aj
� .
OvvnerlApplicarrt �ubdivision
Addr4..ss/Lncati�n � S�4�ase i.�it #
St2#e 1D/d�ie 5"f,6 �2�f 5�'f��
Capaciiy �,c�, 9ai. .
Tee and Ft�e� �
Baffie .
Sealarrt '
�- Tfenc#� Widih ? , ft.
Trench. Depth _ � � ln,
. • Tre�ch Length . 2.� ft.
Trench Grade � �
Trens� Spacing •
' Riser i� ap licable) ' Ro�c Depth artd Quai'tiy ✓
� � Tank Ou�ei:�Sea! . � � � . c%'' I�arnsJSte ovur�s �et�,
. Perman�rrt IVi�rk+er . . . .. Pressure Lai�rais . - .� �
� Pum� 'ian�C . �^ .� Hole �Spacing � , .
: � tate at� � . � a e ize � � �
. . . G�paciiy. ' � � � .gal. - . _ : Pipe Sieeve .
� . . = V1laterproafi /Seatarrt : � � - � � � Tum-u �1Proteciors • . � -
. . . Riser . ' • . � . Re�asin� S�acks: . . . . -
Wa�r Tigi�fi . Frorn W�ils •: "
�ua�p -� From Property lines •
. � �bedc Vairt�/Gate 1Ja��� : � � �• : Structur�sl8aseme� .
. . _' . �� . �tr-sip • �n o e � . � . • • . � ... es eainage ays
_ :. - �: . � �=ioatslSwiich�es � • . . � . .-. . s . _ . � . _ . - -Surface��V1la�ers '
�� � � Alarm� visabde and audible Pubiic Water Sup iies
Eiecficaf Campanes�ts - Vert6cai Cuts ->2 ft.
Rate g rn � 1Nater Lines �
Ag��roved P�m lulode� Vehicie Trxfftc
�loc���.lnder Pump .�d'acent•Sysiems
Pumg Remaval Rop�lC9�ain_. EasemesYtslRight of Ways - �
' �Distrlbtrtaon ���rt ' �ea�
� ��rial Distribution ' �asemerrt� Recordesi _
' ressr�re an' I �� pe r orrtract .
� Low Pressure Pipe � Tri-Pariat� Agr�m�tfc
A��r. Pi�� Nlateriad and. Grade �
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W 9�91i..+ S�'iHl1W1��
��SE SEE �'�'AC��1) PI.A1�T ��It ��. SI'i'�E �.A�`��U�
']Cax Map #: ��U l�arce� # `'T �� Township
APPlicam� I�9ul � a►'
SAbt�1V1S1011: � lS��'1 f Q f �'�'�{��' Sef:LI021: � t � �� '� � / L[7�.M ` ` �
�ACd�IIOII:' �
��GCS �l � Go l�n� �, (
'I'�e of Water Su�wl�r. � Individual Community Public
Requireffient�•
Site Approved y✓'� C'_�� q� l�'v3
Grouting Ap oved. by /C`_,�� ��� /-�3
Well Log
Well T ._ �
Air Vent � /'
Hose B�
Concrete Slab
Well Driller. ` �� ` �
We11 Approvesi �y: Date• ����' -
�°5ee Attaclaerl. Site Sketch�*
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 foundation.
Other conditions:
PCFID, rev. 09/07/01
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_ _ - �- � � TCT�T'�� �0� �° �03 � r �� �
�in� vn.�r^� rr.2�'n'na��atE�.Il IL-3C�.,�.Il�I� DD� LJUWllUl9J .'/ /
� � Grout Log
Owner: _ �7`!L-C��12.IZ„ Tax Map �� Parcel # C�G.S
Location:
Subdivision:
Lot #
Well Construction
Distance From nearest Property Line (Minimum 10 feet) l�
Distance from Se tic System (Minimum 60 feet) �Gv
Total Depth: /�O ft Yield: �.C_'J GPM Static Water Level: a` � ft
Water Bearing Zones: Depth � ft �b� ft ft ft
Casings �
Depth: From d to 8 a ft. Diameter: �/f in
Type: Galvanized Steel �/'
Weight: Thickness: /g� Height above Ground: �� in
Drive Shoe: � Yes No - Any problems encountered w�iile setting casing? Yes �No
If "yes" give reason•
Grout:
Neat: SandlCement Concrete Gravel/Cement �
� Annular Space Width inches Water in Annular Space Yes No
Method of Grout: Pumped Pressure Poured /' Depth �.7 to � Ft.
Materials Used: �
No. Bags Portland cement �l Weight of 1 Bag � Pounds �
If mixture (sand, gravel, cuttin s) - Ratio 2- to �_
ID plates:.�. Yes _ No 4 x 4 slab �Yes _ No
Drilling Log Location Drawing
From To Formation �
D � � �
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� S �
t � /�o �9- :
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v
CC�'�-�y
�s�
lY
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I hereby certify that the above information is correct and that this well was constructed in accordance with regttlations
set forth by the Person C t. .
Signature of ontra ID #�� Date �` ��- �3
PCHD rev 09/30/02