A23 103.=
t� � r�
Pe on County Health Department
Sewage System Improvements Permit
Date:��This Permit Void After3 Years
Owner:
Location/Directions:
sR# 3�?
Subdivision Nam� g�• � t n�e Lot #
Lot Size:--,,'�2:� Type of Dwelling: ,
Water Supply: Private: � Public: Community:
Bedrooms: `f `1-.2G.9yGarbage Disposal
Basement � Basement Fixtures
INFORMA N E D B
5����; oaner or representative
REPAIR: REEVALUATION:
-------------------------
Size of Septic Tank: �Q� gallons Size of Pump Tank: �� U
Nitrification Line: � DD X 3 {i�iti �.! �.� u •
Dep�i► of Stone: 12 inches • ��� � i�'►1���
Max Depth of Trenches � `� �`"'" •" �-�fi-ye
Altemative System: Conv. Pump �� LPP Pump /2/$
Remarks: �
Date Well Approved:
BY
Date Sewage System Approved:
Well should be 100 f� from any sewer
Sanitarian
BY Sanitarian
CERTIFICATE OF COMF'LETION
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Contractor.
------------------------- �
Sewage System location, installation, and protection must meet state and lceal '�
regulations. Septic tank should be pumped out every 3 to 5 yeazs and shall be maintained �
by owner in such manner as not to create a public health hazard. Septic tanlc and'ts
nitrif'ication line must be inspected and approved by a member of the Person Counry �
Health Deparunent before any portion of the installation is covered and put into use. If
the site plans or intended use change this pernut is subject to revocation.
(G.S. 130 A-335F)
L.ocation of sewage disposal sewage system sketched on back.
(OVER)
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
�•, supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
"� at later date: Note location of water supplies on adjacent lots.
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02I01/2000 10:44 5971799
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PLANJING AND ZONING
�,eraon County jisalttt 1��trtmant
Envlronm�rrtsl N.allh S�cj��t
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PAGE O1
Tax Mao #: A z3
�ar�st �►: �4�-�/ � 03
�Q� / 7
N N M M P ED CHANOE 51'�E iS
�„LTER�D THEN Ti�� �Mp�$g 9"rRklCT SHALL BECDML INVALID.
1} Parntit requo�tsd by: (Own��la�an�peapac�w owns�: ,�
Hame Phone: Add
Bustne� Phono: ��"9 � �S' ZS 3
�) N7►tna and addetiss o! turr�rft oWn�r.
3) Property Dascriptlo� �ot �xs: �`1Z To�++� ,�. � -� �� J�, , y Q�
dir�ctions to tt� property pnGud road na and umbe�): �
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4) Propos�d v�nd Sttucture �escrlptlon: �eaoh aEfhelc�wing queatfons:
a) Propw D
by 8tick Bu Madular �1. S_ � Wfds C, D0� W�d+ a
c) Numb� oi B�to�ma: `� � d} Nwt��r ot ooatpents ar people to be served:
e) B�semen� Y�a�� No G If ya�. �il ot baw�+Mt 1lxtun�:�.,
f� Garbapa Dispoaa� Ya Q Na�, ,
g} Dime�slona oi Propaad 8tn�oWti: Wid114: � G�pth: -�jJ�.u.c��� �✓ °�
� Water SuPPh� TYp�� P� {MWj�a� �dA� IIj� Pubtk Cl. Ccfmm n q Spcln� 0
Ais amr wsris an a� proparry7 Ya 0 Ny 1 �t yes. locatlon
6) Pleaas lndlcat� D�eirod 8ysb�m TirD�� i�ms can hs �k�d In order atyour proferenae)
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, � PERSON COUNTY ENVIRONMENTAL HEALTH
P�EASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAYOUT
Tax Map #: _ I""1 �Jt � Parcel #_�/� "7
Zoning 7ownship l l- (L • (a ��C� _ rm
Anolic_ant� 1/ I�/ / L� d' � l O �
Locadon:
Subdivislon:
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Section: Lot: ~ _
Improvement Permit
A buildinq permit cannot be issued with only an Improvement Permit
New ,�,L Repair Addition Type of Strudure � Water Supply ���t.[��--
# of Occupants # of Bedrooms "T Other
Basement? 11�.lL Basement F'ixtures.��
Projected Daily F(ow: �g.p.d. Pertnit Valid For. m'Five Years ❑ No Expiration
Proposed Wastewater System Type: T����?I�. —' la rn�(`�(1VP�tC.•�
Pump Required? ✓Yes No
Proposed Repair :_,nta _m,0 � n nhV(i�-��lE,;
Permit Conditions�
Owner or Legal
Authorized StatE
The issuance of tnis p
holder is responsible
subject to revocatio
Date:
�. - � f� •�
ermit by�me Health Department in no way guarantees the issuance of other permits. The permit
for checicing with appropriate goveming bodies in meeGng their requirements. This site is
n if the site plan, plat, or the intended use changes. The Improvement Permit shall not be
affected by a change in ownership of.the site. This pertnit is subject to compliance with the provisions of the
Laws and Rules for Sewage Treatrnent and Disposal Systems of the North Carolina Administrative Code.
Authorization To Construct Wastewater Svstem (Required for Building Permit)
Type of Wastewater System I1 •-�,� Q�!! �-'V�/�as�tewer Flow: � .p.d.
Facility Type: �, � 5�i �_ New �Repair DExpansion ❑
Basement? C�Ges ❑ No Basement Fixtures? 0 Yes 41�Jo
Wastewater Svstem Requirements
Septic Tank Size: - l� gallons Pump Tank Size: � gallons
Total Trench Length: E�et
Maximum Soil Cover. � inches
MaximumTrench Depth:���-+i�s Aggregate Depth�`.��
Trench Separation: � Feet on Center
,(1�A-'� - $.-�
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Other:� Y�_ l.� l��l.�L�� .r (� U.�d /,[�'1�( v i� � .
Permit Expiration Date: � ld —
�
Authorized State Agent: Date: �—
The type of system pertnitte t�tioes �oes not differ from the type specified on the application. I accept
the specifications of this permit
OwnedLegal Representative Signature: Date: �
PCHD, rev. 11h8/99
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Application #:
Tax Map #: Z�_
Parcel #: ,��,_
Person Couniy Health Department
Environmental Heaith Section
SITE SKETCH
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A plicant's Name Subdivision/Section/Lot#
P
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uthorized State A nt Date
System components represent approzimate contours only. The contractor must flag the system
vrior to beQinnin� tl:e installation to insure that proper �rade is maintained
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PCHD, rev.10/1Z199
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PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: ,� d"� Parcei # /V,��
Zoning
Township 1 Wn n � � �`�' `w'rn
Applicant: c�� ����
LocaUon: __ 1 U�r �.�,1 �� ��
Subdivision: l.�l,y___.�0 � n'�" Section:
TYpe of Water SupplV:
Requirements:
Lot• ' "
Well Permit
]� Individual Community Public
Site Approved by ✓ �
Grouting Approve by ✓ � ' 1�"0�%
Well Log ✓ ! l ` �
Well Tag ✓
Air Vent
Hose Bib �
Concrete Slab �
we11 Driller: � C�.��!L�7 �
Well Approved By:
Date: < �
**See Attached 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 any building foundation.
Other conditio
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PCHD, �ev. 11/29/99
Person County Health Departrnent
Environmental Health Section � � .
Tax Map #: �a3 Parcel �: /a 3
Zoning: Townahip: (•u h��'%"�� �-- _
Subdivision: �� �o i D Section: ______ Loti =
Appticari� u��h �-a
�.00�011: ►`�C17�� I1�� �� K� O 1` A� fow�� Yr l:L Pl0.nl0.�lo h Q� � lyil'�i�S U'Y.�K Lo� o �. �
Operation P�ermit
System Type (In Accordance With Tabie Va): ��• Pu'�p �env,
THIS SYSTEM HAS BEEN INSTALLED IN COMPLlANCE WITH APPUCABLE N�RTH
CAROUNA GElVERAL STATUTES, RULES FaR SEWAGE TR@ATMENT AND DISPOSAL,
.AND ALL CONDITIONS OF THE lMPROVE�AElVT PERMIT AND CONSTRUCTION
AUTHO TI N.
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. �- Authoriz tate Agent — '-- �', � I ate
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PCHD, rev. 10l12199 .
Y�RSUN COUNTY ENVYRONH�NTAL I��ALTH
wELL Loa
Date:� ��`� � � Qaj � �il�•( � SR# � ,
Owne�. —��m � �U�I..Y�`�Z-�
I.,ocation/D�ections: • � � .
_ .
Subdiy�s�op Nam�� ,
Drilling Cbn�ractor:
a
c
L�L fF
��T Y cQt�sTRL�CI'ION
Discancc from Ncarest Properry Linc
D�suuicc from Sourc� of
Pc�llucion Q GPM Static Water Level Ft.
Total DeP.th: F� Yield: .
Ft. Fc. Fc._ �t.
Wz�er Bearing Zones: i�epth F�, Diam�tcr� / Inches
Casing: Depch: rr�,,,��� .
' �Galvanized Stee]_ '�
'I'YPE: Stcel '
If �Steel, does owner approve: Yes NO------ I:�ches
1'�eight: __ '1'hickness: • ` Height Above Ground:____.___
Drivc Shoe: Ycs� No . -------
Werc Problcros Encountercd in Setting the Casing? Ycs __ No________
;i "ycs" givc rca.�on: .
Gr�uc: Type. Neat _ Sand/Cement Concrete
Annular. Space Width 12. Inchcs
Water in ,Annular Spacc: Yes _ No_.,.
_ Mzthod: Pumped � _ Psessure_.._ I�oured •�._._
Depth: From _O to O Ft.
Materials Used: No. Bags Portland Cement______ Weight of .1 bag_____lbs.
If mixture (sand, gravcl; cuttings) - Ratio: �o - .
TD Platcs: Ycs '! Nor______ �
4 x 4 slab Ycs ✓ No _
I HEREBY CERTIFY THAT THE ABOVE XNFORMr1TION TS CORRECT AND THA'I'
THTS WELL WAS CONSTRUCTED IN ACCORDEINCE WITH REGULATIONS SET
FOR'j`x gy�THE PERSON COUNTY HEALTH DEPARTMENT.
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Signat�irc of Contract � Datc
'I"ype �I (b) Sy�teffi �spection Cheeklist
Tax Map � Par el #: ��� PIN
Owner: � lQ i Subdivision: u ��
Address: Ph/Sec2ot: ^J
Location: � �.v2
1)--Establishment---- ----_--.... _.
a) type, size and sewage flow in
accordance with permit
2) Tanks
a) tank risers accessible and surface
water diverted
b) tanks and access manholes structurally
sound, watertight
c) sanitary tee(s) in good worldng condition
d) tanks pumped, cleaned out as needed
3) Effluent Dosin� Svstem
a) effluent appears clear, free of excess solids
b) required pumps present, operating properly
c) high water alarm present, operating
properly
d) floats, pipes, valves, disconnects in good
working condition, operating properly
e) control panel enclosure and cornponents
in good condition, operatin properly
fl Drawdown rate: ^' �� �t P-�.,
4) Ground AsorAtion Field(sl
a) no evidence of effluent reaching surface
or surface waters
b) surface water being effectively diverted
away from drainfield
c) diversion ditches, swales, tile drains aze
well maintained
d) soil cover, vegetation adequate and
maintained as needed
e) protected from traffic and deshuctive uses
� distribution devices in good condition,
worldng properly
g) repair area properly reserved, maintained
h) pressure head properly adjusted ,...
YES NO Remarks
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Summary of Improvements and/or Itepairs Needed:
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Authorized Agent f�!•-� � nC-C�'�,/ Date
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