A41 44Analication Date• � —q a4
Amount Pald: � 00 •��
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Home RepiaoemenUAddHion)
APPLICATIOM FOR SERVICES
$150.00f32Q0.OQ
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1) Permit reqwested by: (Owner/agentlprospective owne�): t�-� u`� ���' ��'� �'�'
Home Phone: � " � � s3�-"� Address: �
Business Phone: 6' / """''�' - �- �- �-3
2) idame and address of current owner. C��� ��- ��^ .�{s --T-�c . CL �� r� �ccr"�► �
. '�� �
3) Property Descrlption: Lot size: 'y��•4�.Township: �li�"��/' Subdivisian: r►'v(3GS�'ct Lot#�
Directions to the propertY (includipg road names and numbers): I�i�-ar��(c� /1 r s .�_� z s7,__
4) Proposed Use and Structure Description: answer each of the following questio�s:
a) Proposed „�, Existing ,�, Type of Structure:__��,� Width:� Depth:�._,.
b) Number of Bedrooms: 3 Number of occupan� or peop{e to be served: ol —5"" ?
c) Basemen� Yes,�, No ,�Will the be plumbing in the basement?
d) Garbage Disposai: Yes . No �
6) Water 3uppiy Typs: Private �new �r exis6n , Pubiic . Community_, Spring ._
Are any weils on adjoining property? Yes�o ,_ If yes..please indicate approximate location on the
site ptan.
6) Daes your property contain previousiy ide�lfied jurisdictionai �+retlands? Y�s ido �
PLEASE NOTE THE FOLLOWtNG:
➢ A PLAT �F THE PROPERTY OR S[TE PLAN �IUS7 BE SUBMITi'ED WITN THIS APPLICATION.
➢ PROPERTY ItNES AND CQRNERS MUST BE CLEARLY MARKED.
➢ THE PROPOSED LOCATION O� ALL STRUCTURES MUST BE STAKED OR FLAGGED.
➢ THE 3ITE MUS7 BE READILY ACCE3SIBLE FOR AN EVALUATiON BY THE HEALTH DEPARTl4�ENT
STAFF.
i hereby make appiication fio the Person Cour�ty Heaith Department for a sit+e evaluation for #he o�r-sibe sewage disposal
system fo� the above-described property. I ag�ee that the contents of this apptication are true and repr�esent the maximum
facii'�ties to be piaced on the property. I understand if the s'�te is aiter�ed or the intended use changes, the pertnit shail
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PCHo, rev. o6►27J02
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Ytnpa�ove�ent Permit
Petwit'6�alid for ✓I'+ive Years. Nq �irat�on �� r
Type of Facilit}�: S l� �: t ,.� � New -� �ddition V�ater 6upply ��;aa.
# of Occupant9 .�� # of B ms 3.. Prnjected Daily Flow 3� c� g.p.d. • '
Proposed Wastewater 33��tesn: �x,�er•���.Q . . . Type: `�
�..
ProposedRepair: ._c-rno��.va �a5�, ro.�,�c,�.w.� ' � Type:
Pe�it condit�ons- o�_ �Q �D�. c�.Qo.r. �� -�� N�- �s�;,�-b �•1,
. ' _ `^�,.
�S�C�^i1�s1� _UC?A ��.a-:u� c� r c�,- 21���•. S2c�},� �ta �Qc�n+� Qras�'t�r;'.
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Owner or Legal Represe
Authorized State Agent:
m
Date: a < < ���
Date: / 2 ��-v U
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'Iho issuanco of ifiie permit by tba Health DoQ�hmant in does not guarantea tho issnanca of other pecmits. It is the responsibility of the
applicantfP�P�Y ��er to in aurc tl�at ail Pe�son Couniy F'lanning and• Zoning and Butlding Inspectione requirements are me� 7fhie
Improve�onent P.ermtt ie subject to revocatton if thelite plan, plat or the intended use changes. The bnprovemnent �ermit is not affected
by a•ehange fit uwuersWp of the property. Thls permit wae iasued Ln compliance wit6 the provisions of the North Carolina `Laws ar�d
�y�g�nr c.rwags T�eatrnent and Disvasd ,5`vstems' (15A NCAC.I8A .1900). Neiqter Person Co�niy nor the Enviro�mental Health
gpeclalpst yrarrant8 thet t�e septic tank ryatem wiII continos to fundion saHsfactoritX in the futura or that the wa�er supply will remain
potable. � � • .
�Antho�ization to Consiract Wastewatea� S�ste�ii (�qntred for Bui��aiug Permit) .
* See site plan and additional c�ttachmen�s (�.
Proposed Wast.�water 3ystem: �..,�,.�,�„�.9 � Type �_ 'Wastewater Flow (�o . .p.d.
New ✓ atr F.gpansion . Soil �;TA�t: • a� s g.p.d.! $ 2
Type of Bacility�h �:�i ��.�Qe,' • •�Basement �Yes x No
. . Vi�ast�wa#er System Requirements . .
Size: Septic T�nk: �cx7n gal ,. Pump �ank: --- � gal� Grease Trap: — gal
field: Total Area: /3 U 5' sq ft Total Length y�/v ft Maz�mum'Trench Depth �_ in
W�dti� �3 ft Mininpum Soil Cover: �' Lo it�
ition: s� Distn'bption Bo�a x Seri�l Diatribution
atinns: S' �,�bc c...� Qo �� e�.s,.
Author3zed State Age,ait:
Pea�it Expiration Date: /2 -
Minimwn'ITrench Sepazation: �_ ft
.Pressure Manifold
Date: � 2 --3-vv'
The type of system peimitted is � Conventional Innovative Altemative. I accept the specifications of
the permit. ' f �
O�vneslg.�gal8.epr�sentative: �� Date: a l c '—�
� ' � PCHD7/30/2002
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Name w` l.��Q E ��,�.r•�
Subdivision
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Authonzed te Ag�ent
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Tax Ma.p #�1 �l I Paxcel # y�I
�ection/Lot# �
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Date .
°� sy�, ��a� �res�m �pro���con�ours only. The contrdc�nr mt�st, fTag the syste�n prior to
lsegiraning the installatzon to insure that pmpergrrrde ia maintained ;
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7F�.�-wna�a:v:���:.a�+a��:�►>�:''.;�����,ra.�;-�71� :
WELL PERMIT � �
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map ,� y t Parcel #�I �_ Township: __��{- �i�
Applicant: ��n� l.� �n � n�cr- on�a .
Subdivision: Lot # � ' �
I.00�lOri: � S'7S 7� ov. �°p.9�a �i�11�� ��j ��is w V� ti��a r,.• ls�. 7 J;�
�uH.
Type of'Water 5upply: ✓Individual _ Community Public
ltequirements:
Site Approved By: ✓ � - 7 -os
Grouting Approve�d By GS � _/y��S �
Well Log: �/ � � 7-v5
Pump Tag: �
Well Tag: 5 '
Air Vent: 7 os
Hose Bib: �
Casing Height: a�+ ��1 `' � 5��28'�°'�
Concrete Slab: Z6 6
'Well Driller: �� ���-�- ����(-�
Well Approved by: �
****See Attached Site Sketch****
Liner.
7nstalled by: '
Depth set:
Grouted•
Date: �
Water Sample:
Wells must be 10 feet from pmperty lines. --�_
� Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions: �vf I �� si 1� sl�,r�.h
Date: � 2$ 6�
PCHD rev O1/27/04
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Applicani
Location:
�x M�p � P�rcel #
Subciivision
Phase Section; Lot #
# of Bed�rooms
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System Type (In Accordance With Table Va):
THIS SYSTEM HAS BEEN INSTALLED !N COMPLIAMCE WITH .APP�ICABLE NORTH
CAROLIPdA GENER�4L STATUTES, RULES FOR SEWAGE TREATIVIENT AND DISPOSAL,
AIdD AL.L CONDITIOWS OF THE IMPROVEMEIVT PERiVIIT AND COMSTRUCTI�N
AUTHORIZATIOPd. �
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Authorized State Agent Date
Installed By: �f����,,,�� Date:� 29�oS .
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PCHD, rev. �7/29/04
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����1C ���G� A��P���a�� �u'�����.9�� ��i�� 00 � �
Tax Map # Parcel #�_ Sysiem Type (Tabie Va)
Owner/Arrlicant u � L��� rr�rnr,ses Subdivision
Address/Location � Sec/Phase Lot # �
State � ID/date � - �2c��
Capacity � /DU� gai.
Tee and Filter
Baffle �
Sea(ant
Riser (if applicable)
Tank Outlet Seal
Permanent Marker
Pump Tank
/Sealant
Riser
Water Tight
' � Pump
Checic ValvelGate Valve
Ant�-sip on o e
Floats/Switches
Alarm (visable and audible)
Electtical Components
Rate (gpm)
Approved Pump 1Viodel
Block Under Pump
Pump Removal Rope/Chain
. � Distribu�ion. System
Serial Distribution
ressure ani o
Low Pressure Pipe
Appr. Pipe Material and Grade
Valves
�
�
�
r�$icatiora �.or
Width � �
Trench Grade �
Trench Spacing
Rock Depth and G
Dams/Stepdowns
Pressure Laterals
Hole Spacinct �
Sleeve
i urn-ups�r.roteccors
Requie�d� Setbacks
Fram Wells
From Propertv lines
Surface Waters
Public Vllater Suppl
Vertical Cuts (>2 ft.
Water Lines
Vehicle Traffic
Easernents/Righf of V'
Other
Easements Recorded
Commenis
ft.
>in.
ft.
n
pcf�d rev, 3/13/0�1
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IE�..P��-�����.�.m.Il 7HI��.Il�� � � __ �O `/'� -G
Well Log �,/
Owner. �` Tax Map �l � Parcel # Y l
Location: —� ,
Subdivisio�� Lot #
Well Constra on
Distance From nearest Property Line (Mvumum 10 feet) ld �
Distance from S tic System (Minimum 60 feet} � o�
Totai Depth: �_ ft Yield: GPM Static Water Level: ft
Water Bearing Zanes: Depth / � R ft ft ft
Gasi�tg: � 3
D$pth: From -f � to ��-- ft. Diameter: � in
Type: Gatvanized Steet
'WaBht: `TIuclaaess' Height above Crround• in
Drive Shoe: Yes ✓Ivo � Any problems eacauntered while setting c:asing? Yes No
If "yes" give reason-
Grout: i`�
NCat: Sattd/Cement � Concrete GraveUCement
Annular Space Width inc�ses Waier in Annul Space Yes No
Method of Grout: Pumped Pressure Poured � Depth o to 2� ; F�
Mnteri�ls Used:
No. Bags Pordand cement �/ �� Weight of 1 Bag �? Pounds
If mixture (sand, gravel, cutting — Ratio ta
ID pla�tes: � Yes _ No 4 x 4 slab ____ Yes � No
Drilling Log Location Drawing
From To Farmation
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I hereby certify that the above informarian is eorreei and that this well was constructe� in accordance wzth
set forth by +he P4rson County Heal Degartment.
Sigas�ture nf Cuntractor �� �i�� ID #_�� D�te G��% !
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