A41 37d do (j
A�alication Date; � 1 � � "I � 3 '� � � ��� 'I ' Tax Mau #: N 7 �
Amount raid: 00 .D , �., �7
Receipt #: � ParcEi #: 3 /
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APPLICATION FOR SERVICES .
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT. FALSIFIED,
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): ��"^�� �� Gn� �3� � �-�(�dl�e �f�'rJa�-►
Home Phone: 3�6 �(o`/ 3oS3 ddress: � S
Business Phone: q I�' �f51 �"/ ___-7�_,1;�„--1 ,qlG a-7 �
-�
2) Name and address of current owner. ," �. w�-�c�
, n�r0 � i
3) Property Description: Lot size: 3�(�'2, Township: �
Directions to the p�operty (Incl�{ding road names and numbers): _
� �4 Lot
� o .ea -r — e. - -� � �'1
�Q.tur ��`t� �W/u� �)04iG) . .
4) F�roposed Use d St cture Descript�on: answer each of the following questions: �a �
a) Proposed � Existing D, Type of Structure: .�-c�L' 6c.�r-f- Widih: � Deptff: � f�
b) Number of Bedrooms: Number of occupants or people to be se ed:
c) Basement: Yes_, No Will th re 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�o _ If yes, please indicate approximate location on the
'site plan.
6) Does your properly contain previously identified jurisdictional wetlands? Yes_ No �
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLlCAT10N.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. �
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAi(ED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE 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-siie 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.
y ' � �� f 'd� ��"�. ��
Owner r Lega Represent ive Dat
PCND, rev. 06/27/02
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Applicant:
Location:
t t.. _
>
�
T��x M��� P�rcel #
S�enc�liivi•s�ion
Fh�a�se Sect�ioia Lot +
Improvement Permit
Permit Valid for � Five Years No Ezpiration
Type of Facility. ' �l� ; ' New +� Addition Water Supply���-�-c.
# of Occupants # of B ooms �_ Projected Daily Flow �c� g.p.d. �
Proposed Wastewater System: �,,,�,tiw.� � . Type: �
Proposed Repair: �, ���,v.�Q Type: .L..�a
Permit Conditions: �\\a�� �e 5�,� . 'n(�n;��,h ���c�.s .
�� .. . • - . .
Owner or Legal Represe�
Authorized State Agent:
Date:� � v�
Date: �-a5-vy
The issuance of this permit by the Health Deparnnent in does not guarantee the issuance of other peimits. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are me� This
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 18A .1900). Neither Person County 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.
Autho.rization to Construct Wastewater System (Required for Building Permit)
* See site plan and additional attachments (�.
Proposed Wastewater System:����Q„�,v� Type �� Wastewater Flow t� g.p.d.
New _� Re air E�xPansion Soil LTAR: � 3� g.p.d./ ft 2
Type of Facility:�� (�r,..'.1�,,b �b .��1:�. Basement Yes � No
Wastewater System Requirements
Tank Size: Septic Tank: � gal Pnmp Tank: gal Crrease Trap: - gal
Drainfield: Total Area: 12or� sq ft Total Length � ft Ma�mum Trench Depth ay in
Trench Width y�_ ft Minimum Soil Cover: �� in Minimum Trench Separation: Q ft
. ✓ Distribution Box
is���.,..J S;� s�.o �.
Authorized State Agent: �
Permit Expiration Date:
�/ Serial Distribution Pressure Manifold
�
Date: $-as-c�y
The type of system permitted is _� Conventional Innovative Alternative. I accept the specifications of
the permit.
Owner/Legal Representative: ' �� �� �`'� Date: �" � �C
PCHD7/30/2002
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Ireginning the
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Taz N1ap # R� 1 Pascel # 37
3ection/Lo�# 3�
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n. Date .
r�e�i�eserltd�iproarimate�co�rt�oars ox�y. 1'Ite c
7ut�ion to i�rsure that pmpsrgrade is masntm
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WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map L1 Parcel # 37 Township: 1-#�-� �N, y IS
Applicant: C�,,,,,� l�nQ. �n� .
Subdivision: Lot #
Location: i 57 C�.� ma�, �> > � �„ ��, m.1� �'- � i��x��+�.� ,� _ _
Type of Water Supply: � Individual _ Community
Requirements:
Site Approved By['�S io ��-�y
Grouting Approved By� l�-b-�l
Well Log: .� �-
Pump Tag:
Well Tag: � o
Air Vent: ia o
Hose Bib: a
Casing Height: ,� S 10 / q��!
Concrete Slab: _ )S�j�/__R /Q�
Public
Liner:
Installed by:
Depth set: _
Grouted:
Date:
Water Sample:
�
�
L
V�
Well Driller: � �C �.� �2.�.u"]n1� `
Well Approved by: -�Y�1'C� Date:
****See Attached Site Sketch****
Wells must be 10 feet from property lines. �
Wells must be 100 feet from septic systems.
ells must be at least 25 feet from any building foundation.
Other conditions: ��� �7 F��i-C ��`C�}�
PCHD rev O1/27/04
���. S.� ���.� ��
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�1rn�-a�-�aan���ta�.�n.� ��c�,ra.���a
Applicanl
-Location:
T�x M�p � P�rcel #t
Suhclivision
Phase Section Lot #
# of Bed�rooms
Operation Permii
System Type (In Aecordance With Table Va): � a
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND COIVSTRUCTION
AUTHORIZATION.
� ��-�g-L�ti
Authori ed Sta Agent Date
Instailed By: M�c�,�� ���
Date: �o - �g-��,
t'�S— ��Ic�
S'rB - 32 M
7— �, ��►
PCHD, rev. 07/29/04
S��?iC T�4NK I�6S���ON C9�fE�KL1S�' (Typ� !I - f�
Tax A�IaQ # �� � Parr�! # 3� � Systern Type (Table Va) �i�. .
OwnedAQpiicant " S�6division
AddresslLncation � SecfPliase Lnt # 3� � �
` ,
. Septic Tanic ca�hon es n .
. St2te IDldate �3_3a� �_�-�� � � - - TFencf� Width ft. �o-�q-�:�r
Capa . ,�T�-i�w . gai. •,� Trenct�.Depth � � � � .
Tee and F�ter �✓ � Tr+enctt Len � oy ft. �
Ba�ie � � ✓ Tr�ent� Grade ✓ �
� Sealarit Trertci� S acin �
� Riser tfi iicable �/ Rodc De and G�uaiiiy
Tank Outlet: Sea! � Da�nslSte owns etc. • �
Pem�anent Marker Presse.sre Laterals � �
� - - PumQ Tank � Hole Spadng . - �
� e � � oe ... . . • . . .
. � CaQacity . � Pi e S�eeve . � . . . . � • . _ � �
V1/at roaf /Sealarrt 4� � Tum-u rotect�rs � . . . .
�� � . Riser . � �4�equined Setbac�Cs . � �
Water�Ti irt � � � F�m Weils �. � - . � 'S ���,- ;q-�,�-� ,
. . pump- � From Pmperty lines � .,�. . . .
� �edc Valve/Gate Valve . � � -- - Struct�t'es/Basements.:: � �.- � .
. . �p o e . . . � es ra�na e � a � : .� � . . .
.� �ioatslSwitct�es �: . � � . � . . .. : _ . SurFace` Waters . . . _ . -� . . . . � . -
. Alarm visable and a�dible) Pubiic Water Su lies �.
• F�ectticai Componer�ts Verticai Cuts �2 ft . v
Rate m Water Llnes - j
�4p rnved Pum Mode! Veh�fe Tra�c �
Btodc Under Pump Ad cent� ms �✓� - .
Pu Removai Ro e1Ct�ain Easern trt oi �lUays c/ • �
�Distribution System � Othe�
Serial Distn%ution ' CS �u-tqvw Easements Recorded . .
ressure an' e r �trac�t
Low Pnessure P9 e • Tri-Partate Agreemetrt
Appr. Pipe Material and Grade �
Valves . • � �
� .Carnments' . �
' . pci�d rev. 3113/07
10/07/2004 07:47 4773706
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HUDSON WELL CO PAGE 61
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We�l Lo�
T� M�p � F�cal # ,.�.�
�.ot *
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Dist�uce From ne�a�est � 'Vf�� Ga�rtr�ecqo�
DisGa�ncb fi�om S dc S �� (�imt�m 10 fe�at) ��+p��
�' (Me�imum 60 fce�c) u
Tctal bepth: ft, Yie1d: 5 , .
Wac�t ��"" 4PM Stahc �tcr Levol: �
a r Be�ting Zones: I�t� ` 0�� �_� ft �
r --.�
c��da�: C� 3
Dtpth: Fs+pxn ,�
Type: G�va��zed $Le�l
'Waigh� , t�S 'T
1]r;ve Sh�e: _,,,,CYe� _
if `j►ea" give c�easc�r�:
�_ R. Diauxa�tri: ' � in
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nesa: .(�iT� He� above Grouad: �,in
No AnY Problems ca�cauaterod whiIc a�ttiug c�in8? Ycs No
�rout: ;
Neat: � Sa�d/Ces�at ✓ r C,oncretc �,_, G�veUCement
Anautar S VVids,h �� incbaa Wate� ia AnaWa�^ Spacxs Yes �No
Meth�od af P�ped ,� p� Poined r/ �� tb F�
?K�ter� U�et�:
No. Baga Pa � ceaaeat _�_ Weigh� of 1 Sag „�,� Paunds
If mixtwt ( 8ritvel, cuttings) -- R�tio ���,p /
iD pletaa: Yee � No 4 x 4 s� � Ye� ✓Na
DrIW�e� Lo�
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r E � t � �r.E�T'dr�. -_.t*�� �.�,- � o� �l� � �" �o
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I bercby certify that the abo�re i.t�formaiian is correcx and that thi� well was caastructed in accordanr� vvith regulationa
set forth by t,�e Per�m Cott�ty Heiith Dep;xmie�
Si�ture of (:uatra�tor l..P �`�av ID iY �� D�te J��-le -' �C7^f
; PCHD t+ev 01/16,'a2