The URL can be used to link to this page

A23 15The District Health Departmenf CASWELL - CHATHAM - LEE - PERSON COUNTIES Water Supply and Sewage Disposal IMPROVEMENTS PERMIT �10. ,�+� Date� "� ��'�— Owner: ��"�?'v��'� +��,�� cation: � � � i, � c7� [I/c,si�✓!2- . i .�t�.-� � Contr�act� or'�� i Wa3er Supplp: Private Public Sewage Disposal Facililies: No. bedrooms <� Dishwasher, Disposal, washing machine, other automatic appliances t i Size of tank: ��'�'�"' Nitriflcation line: �� X•3 Other disposal facility: Water supply and sewage disposal facilities location, installation and protection must meet state and local regulations. 5eptic tank should be pumped out every 3 to 5 years an3 shall be main- tained by owner in such a manner as not to create a public health hazard. Septic tank and nitrification line MUST BE INSPECTED AND AP- PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV- ERED AND PUT INTO USE. Date approved: Well: Sewage Disposal: ' � Ceriificate of Completion Date Approved: � Signe�i llJ �!�%f2 �-Gs�'t^'.". Sanitarian /� _ � Sanitarian (OVEB) Location of well and sewage disposal facilities skeiched on back. �\ NOTE: Make sketch of installation showing lot size and shape, location of house, , septic tanks, privies, water i�;upplies, etc. Note special problems existing on lot. Wrste in measurements in order that installations may be located 1 at later date. Note location of water supplies on adjacent lots. �_. T` , I ' � . �on County Hea�th Department � . :�� Well Permit � .,�: �• '��s Permit Void After 3 Y s ur`j vwner: ,��L;-A1�� /�n / h ��-�� SR# � I.ocati0n/Directi0ns: SubdivisionName:-- - Lot# Drilling Contractor. � [1 �` WELL CONSTRUCTION � Distance from Nearesi .Pro�eity Line�.-3 Distance from Source of Polludon "-s :: Totel Dep : FG Yeld: �_GPM Static Water Level �Ft Water Beazing Zones: Depth �� Ft FG FG Ft Casing: Depth: From �_ � / L Ft Diameter: G,., Inches T'YPE: Steel � G anized Steel v "1 . If Steel, does owner approve_ Yes No Weigh4 �_'Phiclrness: / fi�t/Height Above Ground: �Inches Drive Shce: Yes '� No Were Problems Encoimtered in Seuing the Casing? Yes No `--� If "yes" give reason: � Grout Type: Neat Sand/Cement '� Concrete Annular Space Width � :nches Watet in Arutular Space: Yes _ No Method: Pumped Presst�re Poured � Depth: From � to � � Ft ,, Materials Used: No. Ba�s Ponland Cem t� Weight of 1 bag �� Ibs. I f mixture (san d. grave l, cu t t i ngs) - R a ti o: � c o ' l ID Plates: Yes ✓ No ►d 4 x 4 slab Yes �— No � I HEREBY CERT'IFY THAT THE AIIOVE INFORMATION IS CORRECT AND THAT Ti�S WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. • Si�'tan� of tractor Date >_ '�%�� %��f�� %`-�23/; z v Sanitarians Signaturc Date Issued Sanitarians Signature Date Completed Sketch well location on reverse sidc. c� � � �: U� q ��f� �� .(�-eCe1 � q� �� b Permit (EstablishedlRecorded Lot) �_ Reinspection of Existing System (Loan Closing) Improvements Pernut (Unrecorded Lot) Improvements Permit (Mobile Home RE Improvements Permit (Addition) _ Bacteria � _ Chemical ) _ Repair/Replace existing Septic System t for New Well _ Replace Existing Well _ Petroleum � _ Pesticide � _ Lead 1. Permit requested by: , 7. Dimensions or Proposed Structure: owner/prospective owner/agent: idth: � �= ddr s: ��, °� Depth: L O - 8. What type (if any, additions, expansions, or � replacement is anticipated to the structure or facility Uthat this sewage disposal system is intended to serve? a ome Phone #: — 4 a usiness Phone #: � 7=`�--� 7.3 � Name and address of current owner: . Property Description: Lot size: Tax Map#: Parcel#: _ Township:_ Directions to property: Sta`t� Ro d#& Road m��tc. � ,/%�� ,.� /'* Aif • Number of occunants or neonle to be served: Water su y ty�pe: ivate public ❑ community ❑ spring ❑ •e any wells on adjoining property?Yes ❑ No ❑ so, identify location: 10. Type of structure/facility: Proposed: DExisting: ❑ Type of dw��: House: obile Home: usiness: ❑ Type of business: Number of Employees: Number of bedrooms: �_ Garbage Disposal? Yes ❑ No � Basement? Yes ❑ No C�'I�f so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the PersOn COunty Health Depat'tment for a site evaluation for the on-site 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. I understand that before an Improvements Permit can be issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of the site by the Health Dept., this application st�a� become void and all fees paid forfeited. � Signed Own�r or Authorized Agent Permit Issued• � Permit Denied ❑ Plat Observed ❑ �� / ,� J _.�. '� � � � � . - • -__ . �a_3��- � J-�___---------__"_` r i ' / 5�-�- �.�z2 ' �, � � C/� �� t.� : _ _. FACIbRS-S1TEEYALUA770N t1RE�1 ARF.t12 <:; . AREAi3 AREA4 . _ _.' 1. SIAPE (%) S S S S PS D PS PS PS �p U U U 2. SOIL TEXNRE (12-36IN.) S S S S (SANDY. LOAMY, CLAYEY, NOTE 2:1 CLA1� S �„p� PS PS PS � U U U 3. SOIL S7RUCIURE (12-36IN.) S ^n S S S (CLAYEY SOfLS) S �j�s PS PS PS U U U 4. SOIL DEP77i (IN.) S S S S 5 � � � � PS PS PS [J U U S. RES7RIC'CIVEHORIZONS(IN.) S S S S (AIPERVIOUS STRATA. ROCK) S � v PS PS PS U U U 6. SOIL DRAINAG&GROUNDWATER S S S S (EX'IERNAL & INTERNAL) �� I� PS PS PS �� U U U 7. SOIL PERMEABILI7Y S S S (PERCOLAATTON RATE) P � Q�r% PS PS PS e J 1I1... U U U 8. AVAri.ABLE SPACE 5 S S PS %�1< PS PS . PS V U U U 9. 51'I'E CLASSIFICATION(SEE BELOW) SOIL SERIES S•SUITABLE PS-PROVISIONALLY SUITABLE U-UNSllII'ABLE RECOMMENDATIONS/COMMENTS : SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope patterns, etc.) C:WMIPRO�DOCSIAPPSEC.SMFINANCE.PC .' � co �41 O � � .� � �� Q� . a� � i R f �� w PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROyEMENT PERMIT Tax Map # ,�� Parcel # _..%� Zoning Tow ship n Owner/Contractor Date Location/Address " S.R.# Subdivision Name Lot#. �� Layout ,.,.. 5t� '✓� �n� � ��ok , , , ,� � � ��fa� (p•c7�'r✓ + � ' �r `i`� 1 c � �(.17` �w 0748 •_ , _ �� As Installed � r � ��f � �`"(� , �/ � � � , r �ic 77 �, SEWAGE SYSTEM SPECIFICATIONS Repair Lot Area Size of Tank f� SFD Mobile Home t/ Size of Pump Tank y �s # of Bedrooms�_ Nitrification Line�ii0 �� 3! �,.rn J� �. Max Depth Trenches .� �" Permit Void after 60 months. Permit Void if not in compliance with zoning regulations. /i� � . ,� xs�� -----r . -- • •- environmental health specia(ist is not responsible for false or misleading information contained in the application. The environmental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading statements provided to him in the application. 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. c:�amipro\permit.sam O1/95 rev.1.0 1'LRSON COUN'1'Y I:NVIRONM�NTAL I1�ALTI1 Wf:LL I,OG � . Date:�- '- .6' Owner: _LYi - �,-�1L�,�p,._ _ . Location/Directions: ___ __ _ __ ��L�'�vision N�u»c: Drilling Contractor: R � SR# J. � �_ Lo� # WEt.L CONSTRUCTIdN • � Distance from Nearest Prope:r�y Li1ic`/ � �s Distancc from Source of � Pollution_ o � ws � Total De .th: ;� �) ' . p �_ Ft. Xield: GPM Static Water Level Ft. Water Bearing Zones: Deptlz �� Ft. Ft. F[. �t. Casing: Depth: From Q_to i . Diameter: �% Inches TYP:�: Steel Galv�inized Steel ..� If Steel, does owncr approve: Yes No Weigh[:�_ Thickness:��jeight'Abovc Ground: / � Inches Drive Shoc: Yes �~No ? : Were P`roblems Encountcrcd in Sctting the Casing? Ycs No 1 r � It 'yes" give reason: . Grout: Type: Neat Sand/Ccmcnt � Concrete �� Annular. Space Width 3 Inchcs Water in Annular Spacc: Ycs No �- Mcthod: Fumpcd Pressuz-e Poureci .-- Depch: From � �o ,� o_rt. � Ma[erials Used: No. Bags Portland Cement�_ Weight of .1 bag s�lbs. If mixture (sand, gravcl, cuttinos) - Ratio: � to 1 ID Plates: Yes � No 4 x 4 slab Yes � No I HEREBY CER'ITF�T THAT THE AI30VE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH REGULATIONS 'SET FORTH BY�THE PEt2SON COUNTY HEALTH DEPARTMENT. --�'� �-�/�Cf � ..j �y.� � Signature of C'ontractor Datc � : �paltcatlon Date: fO�� . Tax Maa #• �� 3 Amount Paid: �-'d .0 Rece1 t • "a2k3a20 , Parcal : � S' � � 1 �.�� - I�II�IIb.� �� - - -� �c � -�7-1��-- ZLs:a.-Pssm.�.---•-^` .em._�so.71 ]E�ae.m.]1.�IEa 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 �P��i 1) Pertnit requested Home Phone: � Business Phone: r 3 � .�.��jso�T" � 2) Name and address of current owner. Address: 3) Property Descriptian: Lot size: Township: Directio�s to the prope�ty (IncJuding roa�t names and Lot �� wt�ls / ' 4) Proposed Use and Stwcture Descriptlon: answer each of the foilowing questions: a) Proposed � Existing , Type of Structure: Width: � Depth: ) Number df Bedrooms: Numbe� of occupants or people to be senred: c) Basement: Yes�, No _ W(11 thsrQ be plumbing in the basement? d) 6arbage Disposal: Yes , No` 5) Water Supply Type: Private (new ,_ or existing� Public� Community� Spring _ . Are any wells on adJoining property? Yes 1/I I�o _ ff yes, please indicate approximate location on the 'site pian. � 6) Does your property contain �reviousiy identffied jurisdtctional wetlandsl Yes_ No� PLEASE NOTE THE FOLL��NG ,. , ;;; . ➢ A PLAT OF THE PIROP�RTY OR SI'�'� PLAN MUST BE SUBMITTED WITH THIS APPLlCATION. ➢ PROPERTY LINES AND CORNERS MUST BE CLEARt,Y MARKED. �, ➢ THE PROPOSED LOCATION ,OF �1�L, STRUCTURES MUST BE STAiCED OR FLAGGED. ➢ THE SITE ML1ST B�E READILY ACG�SSIBLE FOR AN EVALUATION BY THE HEALTH �EPARTMENT STAFF. 1 hereby make application to the Person . County Health Department for a siie evaluation for the on-site sewage disposal system for the above-desc�ibed.p�oQerty,- I.a��Q that the contents of this app�ication are true and represent the maximum facilities to b laced an tt�e properiy. I u'nder�tand if the site is altered or the intended use changes, the permit shall beco . , �� ' - a��d Owner or Legai t��P�ase�iauv Date " PCHD, rav. O6J27/02 �� : �� , , ,. � �..�. ,> �:� �� II��:�ax,aroaa.ac-�a.��.7L IF��,�;]L.�ILa.:: WELL PERNIIT - PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Map 1�" �- Parcel # Applicant: �C�wt�� Subdivision: � , . Township: Lot # Type of Water Supply: � Individual _ Community Public Requirements: � Site Approved By: Liner: Grouting Appr ed By: �`� � Installed by: . Well Log: � Depth set: _ Pump Tag: Grouted: _ Well Tag: Date: Air Vent: Hose Bib: Water Sample: Casing Height: - Concrete Slab: Well Driller: ��'� Well Approved by: ****See Attached Site Sketch**** Wells must be l0 feet from property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from any building foundation. Other conditions: Date: PCHD rev O1/27/04 0 �� s �� I .�. � �. , . . �---= _ � � �� . IE��sm�.-e,.-..-.. m��.71 �m�Il�h� SI'TE PLAN Nam ��^ ��► "�'G� ' "` Taa #� Parcel # I � �P Sub " ' Secrion/Lot# Authosized State Agent Date � System compaaeats �r�.+vmt sppaux�sae aonrours mly. Tlu caau�crormuet9ag the syatrm paor m begianiag �e ias�larioa m ,.,m,,.. �P�P�'�dei�msmniaed rcxn, n,•. o�/�z/oi , �� 2 �-�,, . . � ��..� ��T : . �_ �� I� �n.��.a�-�sa��arA.c�a�cn.��►:31. 7�ZC��:7l.�Ihi : WELL PERNIIT PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Map o�t � 3 Applicant• Subdivision: Location: r, # 1 � ,, _, Township: Lot # Type of Water Supply: � Individual Community Public Requirements: Site Approved By: � Grouting Appro ed By: —' � Well Log: Pump Tag: Well Tag: Air Vent: Hose Bib: Casing Height: - Concrete Slab: Well Driller: �t r ►�� Well Approved by: ****See Attached Site Sketch**** Liner: �Installed by: Depth set: _ Grouted: Date: Water Sample: 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 conditions: Date: PCHD rev O1/27/04 ��.s� ��.�� 2 . . _. _ �� . �� . STTE PLAN Nam Qi�s � i✓i�"�- ' Taa Map #/��Parcel # �� S Secrioa/Lot# Authorized Stau Ageat Date � System aomponeata irprrsmr appuaaimsae uvamrna m1�. The oaatncmrmust9�g t6e s}astrm pnior m begmniag the iosmll�tioa m :••m•,� �P�P�i'�deismsint�ed � i 7' - � � �� e �- �� . c� �� C�S��" e � N IS° � �o . ... } ,� �a�2- G 5't-uv-e� � � � � .. _ �a �--� C�► rPe f-� QCvo SS -�� V�I r� �d r vt pl� 1Ct'fr S�v i�1`e.. � � _ _ . � s�C rcxn, m. o�/�z/oi � ��;�. f �I�I�$:� ��T �� ':� � �� aa�nso�c�a��TM�+ �s:a��s:�: ��m��n. Owner: �'/�' Location: �. Subdivision: Drille.r ID # ! � .r � Com�p�ny Na�me ,/ D�t�e Drilled � �/ Grout Log _�-` �� Tax Map �3 Parcel # If Lot # Well Cons�rn on Distance From nearest Property Line (Minimum 10 feet.� D�� Distance from e tic System (Minim 60 feet) � U_ Total Depth: _�� ft Yield: � GPM Static Water Level: _ Water Bearing Zones: Depth %� ft ��_ ft ft Casing: Depth: From _t� to� ft. Diameter: ie z.in T e• Galvanized Steel � YP • Weight: Ttuckness: Height above Ground: � in � �� Drive Shoe: c%Yes No Any problems encountered while setting casing`? Yes l/No If "yes" give reason: Gront: Neat: Sand/Cement Annular Space Width Method of Grout: Pumped _ Concrete GraveUCement inches Water in Annular Space Yes No Pressure Poured Depth to Ft. Materials Used: No. Bags Portland cement Weight of 1 Bag Pounds If mixture (sand, gravel, cuttings) — Ratio to ID plates: _ Yes _ No 4 x 4 slab _ Yes _ No Liner: . Depth: Date Installed: Grout: Installed by: Drilling Log Location Drawing From To Formation a ov�h �. �t v � / . b tf�D L � �i� G,. 3�,u-c �+�! �/° Y �" � �� I hereby certify that the above infonnation is conect and that tlus well was constructed in accordance with regulations set forth by the Person County Health Department. ' Signature of Contractor ID# �� Date �7 � Pump Installment Pump Installation Contractor: Pump Depth: ft Static Water Level: Pump Make & Model: State Registration Number: ft Pump Size and Rating: hp gpm I hereby certify that this pump was installed and the well head completed according to the Person County Well Rules in effect on this date and that a copy of this record has been provided to the well owner. � Pump Installer Signature Date: PCHD rev O1/27/04 _� - � s � y�� LNUUII�`il! �� Li? �n � Z/ �� '' . '� � IS�_�ns �r Cir. ��,7nr. � � ��::. � IE��aa-��,.-„-,. ��:]l IE��.71�7�. �Q� �- a �- / 7- O5� Grout Log Owner: k,.n t� �o ;•-�-c �..lf�; Tax Map Q�-� Parcel #/b'� Location: Subdivision: Lot # Well Construction Distance From nearest Property Line (Minimum 10 feet) Distance from Septic System (Minimum 60 feet) Total Depth: 2n� ft Yield: �� GPM Static Water Level: 2_S ft Water Bearing Zones: Depth J_Q��$ �� ft �g�� ft ft �� _i Casing: Depth: From _� to �� ft. Diameter: � in Type: Galvanized Steel Weight: 'clrness: ,�_ Height above Ground: _�� in Drive Shoe: _�Yes No Any problems encountered while setting casing? Yes ✓l�To If "yes" give reason: Grout: Neat: Sand/Cement Annular Space Width Method of Grout: Pumped _ ✓ Concrete GraveUCement _ inches Water in Annular Space Yes No Pressure Poured � Depth _� to �� Ft. Materials Used: No. Bags Portland cement � r�� Weight of 1 Bag S`L� Pounds If mixture (sand, gravel, cu gs) — Ratio to ID plates: �Yes _ No 4 x 4 slab �/Yes _ No Liner. Depth: Date Installed: Grout: Installed by: Drilling Log Location Drawing From To Formation 1�: r� i✓�: J� f : ', .5 70� y i �� ' � � y�ir�] - l�i /l ��, I hereby certify that the above information is by the Person County Health Departmen� Signature of Contractor Pump Installation Contractor: Pump Depth: Pump Make & Model: and that this well was constructed 'm accordance with regulations set forth ID#�� zy Date �' -/ 7- oe� Pump Installment ft Static Water Level: State Registration Number: ft Pump Size and Rating: _ hp gpm I hereby certify that this pump was installed and the well head completed according to the Person County Well Rules in effect on this date and that a copy of this record has been provided to the well owner. . Pump Installer Signatare Date: PCHD rev O1/27/04