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A41 5� � N .. w y z �� � �b y�p .. m L�. w �o. � ��� °�� � �. "' '�C � O � n � �p' t�+. � o . � � y a-F � � 1�--� � � w w �: � y � �! �p h7 �. O ' J "� Q4 y �' � � h o � � �. w � m �: � �D � �• ¢. y � w y '� � fD ti fD o � � y �. 5 "J � �:+ � y O w � r. y � `° �, 'a n � °,« � N y � � Q• �• N rn o � n �' w � � a :; i ; The District,Health Department � prange, Person. Caswell, Ch,a3ham. Lae Counties _ " F � ' Water Supply ;�r�d iragRavE��rrs - ,� _.�- , . : �! _: r..� Location• - �� ` " y �� i"" _ ' � �, � � t � : C' �t�� � xa�c+ ��-;�. . �,#�, �} ` � �I Contractor: ` W er Sup ly: Private �-� � blic y�,,sa, t�' � 1.+�� � � � ; i�.�=-l�� ��,�0 � �"� �-- � t.:p; �����ishwasher, Disposal, Sewage Disposal Facilities: No. bedrooms washing machi e, �� rf�ut�O�atic �appliances , s� � Size of tank: �� � ' NitriScation line: ; Other disposal facility: . " Water supply and Sewage disposal':facilities location, installation and protection must meet state and local re�ulations. SeptiC tank should be pumped out�every 3 to 5 years and shall be maln- t8ined by owner in such a manner as� not to create a Aub11C he3lth h3Z1Td. Septic tank and nitrification line MUST BE INSPECTEB AND AP- PROVEI3 BY A MEMBER OF THE DISTRICT HEAi.Tx nEPAR.TMErrT F.RF.D AND PUT NTO USE ON OF THE IN5TALLATION IS COV- Slgri �r i �'--x1�..` �R `---�'��"'r�x �p� ,,� Sanitari , Counter- ,� �'; . .�'_•_�� - d. aigned�`"•�' .`-'-;�',o: ;-`�.�- ,;� (C3'wner or his represen�ative) / ! � Certificate of Completion „.. � ..�---- �- ,,- ;,; t�`;� _ �r �. � 1 ^ gy;��.,,V " ` � . _ Date Approved: , $ant�arian f U �— (OVER) Location of well and sewage disposal facilities sketched on back. Apalication Date: �r� � v � � Amount Paid: � RecEiet �: Tax Man #: ��1 I Parca! #• J �� •�1�'?� �� ���� �� g3 I 1 - - __ ������ �.a�a_vn.a-�,�ra.�-^�-�• �saa��.I1 �'-�Lo.m.7L�I1a / APPLlCATION FOR SERVICES � <' IF T!-iE IPIFOFtM�►TIOtV IN Ti-19E APPLICA'T10N FOR APd IMPROVEMEflIT PERIIAR IS II�CaRRECl' F�►LS1FaE� C�iAhIGED, O0� THE SITE IS e4LTEi2ED. THE�f T�iE 1�ttPROVE3I�EAIT PE3iI�IIT AND AUTNORI�TiOid TO COMSTi�UCT SHALL BECONiE INVALID. • 'f) Permit requesi�d 9ay: (Owner/agentlprospectiv own Home Phone: �`�9' � 6q � O Address: .� � ' � Business Rhone: � � ,. . ,� 7� � � . 2) Alame and addr�ss of curreni vwner: .� s 3) Property Description: Lot size: 3���Township: � + Subdivision: Lot # Directions to the p�o erty (lncluding d names and numbers): `7 — 9� � rf , a� a _ G�oZC 4) proposed Use and $truc#ur� Description:, answer each of the following gue�tions: a) Proposed . Existing , Type of Structure: Width: � Depth: s b) Number df Bedrooms: � �. Number of occupants or people to be served: c) Basement Ye�_, No . Will there be plumbing in the basementT � d) 6arbage Disposal:.Yes �� No _ - 5) 1A(ater Suppiy� Yype: Private t/ {new 'V or existin9� , Public� Comrnunity , Spring _ � Are any welis on adjoining property? Yes VNo _ If yes, please indicate approximate location on the 'site pian. � . � 6) Does your property cantain previo�asly identifled jur�sdic8ional wetlarads? Yes_ iVo `= PLE�►SE !�O'TE THE FOLLOIfl►IMG: 9� PLAT OF THE PROPEi�TI( OR SITE PL4lV MIDST BE SUBMITTED WITH THIS APP�6C�►T1�N. 9 PROPEiZTY LINES AIdD CORNERS MUST BE CLEA6tLY MARKED. �, ➢ i'HE PR�POSED LOCATION OF ALL STRUCTURES MUST BE STA6CED OR FLAGG�D. �'�HE SITE MU$T 8E t2EADIL�I ACCESSIBL� FOR AN EVALUATIOPI �Y THE HEALTH DE�AR7'iViEiVT STAFF: � I hereby make appEication to the Person County Health Department for a site evaluation for the on-siie sewage disposal system for the above-described property. I agre� that the cantents of this application are true and represent the maximum faciliiies to be plac�d on the property. I understand if the site is aitered or the intended use changes, the permit shall became invalid. ' � ��jalv � �cC � ���— �) �1 � � 1 Owner or Legal Representative Date PC;10, rev. 06127/02 .����::`.�'`.'::�:'��:';.. . �. ,.'�� . � . r`����• :�1:�'`�� , �.. ''� ::��•i`i.. ��• . �„^:v ::;•:..r... . �'q jj . .. ` t'i::,,L"�'!.�.`�`�.�.� �'.iGs:�,v.�:a���i:�++:� �;;;s�?�i�;�n;Zl'•�';��-`�:��,a�.3L•'�7E�i:: ��]� P��.�� PLEASE SEE A�Tr��+ ��d..r4I�T F�,IIt �I.,� SI�+ LA3IOgJ7[' Tax Map ��l I Parcel # 5 Township: Applicant: _ �,��nl-� �t �z�,rs 5ll�7�1V1910Il: LOt # • Location: IS�T -� �3 � �n�rs wh��'e1� Rd � Coa� ,�o,�rs ��/hi�-�ie1c1,�'d '�yp� of'VVater 5upplly: � Individual Requireffients: Site Approved By: �^ Grouting Appraved By: ' Well Log: � ✓ " Pump Tag: � Well Tag• � � Air Vent: � � Hose Bib: � Casing Height: � Concrete Slab: � Well Driller: Well Approved by: ***�See Attached Site Sketcih***� Colnmunity Public Liner: 'Installed by: _ Depth set: _ Grouted: Date: Wate� �ample: Wells must be 10 feet from property lines. � ��Wells must be 100 feet from septic systems. ,� Wells must be at least 25 feet from any building foundation. � i� .�� ��� ►. t��� � ' t ..� Date:. PC�ID rev 01/27/04 `��? )� ��1L�1�`�J� �-- _ �-.r— �: � �� � �' ]E��a-�,.-,.,.-�.-�.���.�.IL I�33L�.�.]L�71� SITE PLAN Name ���L�:rS Taa Map #� � Parcel # J� S �vision �- Secrion/� t# '�nJt�s.B i_�l� j� Authorized State Agent Date System camponents rep�esent appmximate rnnrours oaly: The conua�ctormusttlag the system pdor to be 'gnni a,f, theinstallstioa m lnsure rharpmpergrade is mainrained a �ea .� ��'�,.e� .��' ��;c t�6e K �*^� 5u�� Wel� si� is lo� �� ��� � well ► � t�M�rkec� W�h bl►�e �lo� �n . . �� � � E loal R�S �•�hi��eld � Scale: N �l N� � t�►�vS� Obc�,r�d�n �KiSk�r� w��\ ('�°��"j � �� ��� � c�ac� ��. ���� ' ��� — �-r�lc� PCHD, rev. 09/12/Ol - _ _ .'• -' r:i:f -r �-�:: . ' �.�"}"::••'�"n:�' . ....� . ..,. , . .. _ . .� q- �_ . . .•.�-� _ . . Y = o���- � :��� �1 �� � ����:��-:� � . ���---��{ _ -- �� �� � :�.-���:-. . -� =, :�:� �::����- ��.��,���.�,.�.�: ����.� :: D� D�c�i . . .. � Location: Subdivision: Grout Log �j � � � Tax Map /rZ� Parcel # � Lot # . - WeII Constrac.tion Distance From nraresi Property L'me (Miuimum 10 fcet) (�o � Distance from Septic System (M'mimum b0 feet) Total Depth: �� ft Yeld �` __-_ GPM - tatic Water I.eveL- Water Beazing Z.one.s: Depth�_ f� � 3�__ ft ft ft ft Casing: � Depih: From .�_ to �� Diam,et�: _,� in . Z`S+pe: Galvanized Steel - Weigh� Thiclmess: .� i�l Height above Gmound: in � / Drive Shoe: v� Yes No Any problems encountered wh�e setting casing? _Yes _� No If "yes" give reason: . . Groni: � . Nea� Sand/Cetnent Concrete GraveUCe�ent / . -•. Aimular Space �Vidth • mches Water um Ann Space Yes �` No Method of Grou� Pumped Pressure Poured � Depih �_ to �� Ft Materials Use�L- � . No. Bags Portland cemc�t � Weight a� 1 Bag Po�mds . ff mndtme ( gravel, cat�n&�) — R�tio to - ID plates: �Yes _ No 4 x 4 slab ✓Yes No Liner: , - - -.,. Depth: Dat� Installed: Drilling Log Grou� Installed by - � Location Drawing � ��� � �� ������ - �'r/� �. '�_...��'i'.��'� ■ � � �I... ..... . ; � � �. �� , ,� �� , ' I hereby certify tbat ii�e above� iafa�ation is coa+ect and t�at ti�is well was G�ns� in accardance wi� regulations set fa� by the Person County Health Deparbmeat. , ' . Si�gaatnre of Conirxd�or I m# 3�fG ,��. —z��o7 �'amp Instaument Pump Installation Contractor_ �/ �j/G �� State Regislration Number. 1P �� �P �F� � fl $ Sfatic Water LeveL- 2S' ft Pump Make & Modei- /�ie� S P�p Size and Rabn�- '1 L hp �_ gpm I hereby certify tlmt this pwmp was installed and t�e wetl head completed acc�dmg to the Pexsan Couaty Well Rules in effect an dus date and that a capy of this record�as been �ovided to-fi�e well owner. . �P �II�' �'e-_�%ii.." l �,-� � , Date: ' 2�^+� � P(;HD rev 01I27/04