A23 166♦.- '
. �'_-�
-��- �
The District Health Departmenf
CASINEL� - CHATHAM - LEE - PERSON COUNTIES
. �
Water Supply and Sewage Disposol �
IMPROVEMENTS PERMIT No. �
, � ,, Date' � g � � `
Owner: �
Location: � ' �
���� � �
�
Contractor: � ��1 � � ---
�o
Wate: Supplp: Priv 'te �Public ^
r I�I �. -�-_-� ��—�- � ,
Sewage Disposal F�cilities: No.
washing machine, other suton
Size of tank: ,[.�.��!T�s
Other disposal facility:
lrooms � � Dishwasher, ' posal, �'�
� appliances
Nitriflcation line:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years an� 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-
PROVEB BY A MEMBER OF THE DISTRICT HEA TH DEPARTMENT
STAFF BEFOftE ANY POATION OF THE IN L TIO IS COV-
ERED AND PUT INTO USE.
Date approved: — Signe
Sanitari
Well:
Sewage Disposal:
By:
CertiScate of Complelion �
Date Approved: ���T
�
Counter-
aigned
( ner or h' presenta ive)
� Permit YOID after 3 Years �,,,..�-
1 ���
1' � �. .
!� ; ; �� ' ����1�
, 1r � !
gy: � �
Sa�iitarian ,
(OVER)
Location of well and sewage disposal facilities sketched on back.
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
� �� �
Person County Health Department �
` � � Well Permit �
Date:s-�3-`ll 'Fhis Permit Void After 3 Years �!' -�'�
Owner: QU n n� -f_(�-r � n y i GL I rloYD � SR# /32 3
Location/Directio�
Subdivision Name:
Drilling Contractor:
Lot # I
WELL CONSTRUCi'ION ►�
Distance from Nearest Praperty Line_ 1 ��/v� Distance from Source of
Pollution ��P /(., S � �
Total Depth:��Ft Yield: �GPM Static Water Level F� �
Water Bearing Zones: Depth �� FG�FG FG �
Casing: Depth: From � to ,� F� Diameter: � Inches
TYPE: Steel Galvanized Steel �
If Steel, does owner approve: Yes No
Weight: ..�_ Thiclmess: � Height Above Ground: �17i Inches
Drive Shce: Yes �� No
Were Problems Encountered in Setting the Casing? Yes No v
If "yes" give reason:
Grout: Type: Neat " Sand/Cem�t Concrete
Annular Space Width .3 Inches
Water in Atmular Space: Yes No �'
Method Pumped Pressure Poured �/
Depth: Firnn �_ to �_ F�
Materials Used: No. Bags Portland Cement � Weight of 1 bag
�_ lbs.
If mixture (sand, gravel, cuttings) - Ratio: ;� to �_
ID Plates: Yes C� No
4 z 4 slab Yes L/ No
I HEREBY CER'I'IFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT.
� _ , I
Si of tr Date
� .5�/z3l
anitarian s Signa Date Issued
�P �. ��'
Sanitarians gnature Date Completed
Sketch well location on reverse side.
,�
,�
� 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.
r (1) S�.`•'H' 1323 c2�
�■■��_ —
■■.■■■��� ��I-i�i/�■...■■■■■■■■■.r
■■.■■■■■�■� "��■,.■■■.�■■■■r■■
■■■■■■■■�■fLL��..■■■■�■■■.■■.
■����■�����!� l:������I�N����
■��e������� � ■ ■■ ■ ���■
■����.����i��F�� ■ ■o ■■ ��■■
■■■�■I.��.�■��' • ' ■�■■ ■■■■■■■
■■■■.■�� ■■■■■ t ■■■.■■■■■■■.
■■■.�.� ■■.� �.■■■■■■■■■■.■
■��t��!: %�i�■ ,�������■■���■
■o�����•�-■��■ �.���■■����n�■
■������•������,��������■■ ■■
i
�o;unC
Rtt�cei�t
�
�
w
U
�
Q..
paid o2� � v`�
!1 � � 1 �
. v�2 3 '1'Z �. .
( j�,�a,� �ec� i N )
_ .S",��7�9'7 - -
D'ate
L1VltJG. u aravw�v .a.....�. .�p — -------- �
Type of business:
Number of Employees:
'Number of bedrooms: 3
! Garbage A'sspasal? 'Yes O No �
iBasement?'Yes❑ �Ia� Yf so, # of basemcnt fixtures:
C�.E1�RI;Y' STAK� ALL CORNEXtS OF T� P7,t4PERTY AND 'X'�IE CORI�I�RS O� �.'�'I'
pRO�'QSED STRUC�`�3�tES•
I h�ereby make application to the T.'ersOn Coun�y Health DepaXtment for a site evaluation for the on-sit�
sewage disposal sysiem for the abo�e descn�bed property. i agree tltat the contents of Lhis ap�licatior► are tcue
and represeni the maximum faciliEies to be placed on the proparty. I undersEand if the site is altered or tl�e
intended use changes, the permit shali be�come invaIid. I understand that before an �mprovements i�ermit can t
issued, I must present a survey plat of the peny to the Health Degt. � understand that in the event I have no
i delivered a survey plat of the proporty thc Health De t_ wis�iin 60 DAXS after the date of the evaluation of
� the site by the Health Dept., thi� ation�hall �r,�e %�i�nd ali� � forfeited.
� � f/ U` � SiQncc� �wnet g��uthocizcd Ageat� .
� TOTAL P.�1
Permit Issued ❑
Permit.Denied ❑
Plat Observed ❑
Signa[ure
�
Date
��
. . . .x .. .. . . - S rli�'zc?'� r y��aE%+�^�.,�r ,�'. �E s��,u�
. . ..
g'�'.<i��ry'.���,�' ��^�F���/�Gi'bA�SiT`Ek1!ALIlAT7Q1��;,"�4* s.�a.>�fr�,'*�.,t'„�,s L. ��n���ks.» ,,./�itE�'Z�t�. �'�s,�.�'t:s��.ct7x.�",k�',s�.'��"`��-.. .��� �+�s
.. .
,<.:.... , .. :. ...�.�.-.-. ,
�s`. <
1. StAPE ('41 S � S S S
PS PS PS PS
U U U U
Z SOII.TF�C'tURE(12•36IN.) • S S -, S S •
(SANDY. LOAMY. CIJIYEY. N07E 2:1 CLJ11� PS PS PS PS
' U U U U '
3. SOiLSiRUCTURE(II•161N.) S S S S �
�Q�yEySpRSi PS PS PS PS -
U U U U,
3. SOILDEPiti(IN.) S . S S S
PS ' PS K PS
v u u u
3. RES'IRICIiVE HORRANS (tN.) S S S - S•
(II.SYERYIWS SiRATA. ROCK) PS PS t5 PS
U V V U
6. SOiLDRUNAGFJCROIJNDw�7E� S , S s S
tE7Cl'f3t1t11L R II:TF3t1tl1L) PS PS PS PS
U ' U U U
7. SOII.YE3t3RFJl8lL7iY S S S S
(PFACO[AA110N RA7'E� PS PS PS PS
• v v u u
E. AVM,ABLESPACE S S S S.
PS PS ►S �
U V U U
9. SCiEC1J1SS[FIGlT10N(SEEBELO�
SOTLSERIES ' ' '
• �
SSUlTA6LE TSTROYt170NA11.YSlJITADI,E ll-tRtSUCCAELE
RECOMMENDATIONS/COMMENTS: - ,
SITE CLASSIFICATION DIAGRAM (Include: Soil areas, properly lines, roads, streams, gullies, wet areas, �i�i
areas, wells, water bodies, slope patterns, etc.� . CMMIPRO\DOCS�APPSEC.S�1 FlNANCE-PC
a
•------.
. .—
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION Il�'ROVEMENT PERNIIT
B 1648
Not for waste water system construction. No permit(s) for Construction Location or
Relocation Activity shall be issued until Authorization for waste water system construction
has been issued.
Tax Map #_ ,�� �
Zoning
Owner/Contractor � � .P�� n P
Location/Address
Subdivision Name
Parcel # % �p %
Township �' �nn � i�► �i ii Q�+�
Lot#
SEWAGE SYSTEM SPECIFICATTONS
"' Repair Lot Area�� G �.�P
� S� Mobile Home
Business # of Bedrooms�_
�
a
�,Wj Permits may be voided if site is altered
� Well and Septic Layout by
a Comments:
Date��� Installed by,
S.R.#
Size of Tank �r's�i.-; /Ul/�/�,�-
Size of Pump Tank
Nitrification Line_ �� �' /�d �X 3
Max Depth Trenches___ -
use
� oc1 ga�°" �/ �-�o-`i7
'ell Permit Paid � WELL SYSTEM SPECIFICATIONS
dividual�_Semi-Public Required Slab
�blic Replacement Air Vent
te Approved ✓ Required Well Log
ell Head Approved Well Tag
Comments:
Date
Installed by
by
Approved by -
This report is based in part on information provided the homeowner or his/her
representative in the application submitted for this permit. The environmental
health specialist 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 properhy 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.l.l
�
" ' AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Void sixty (60) months from date of issuance)
DATE: ^=IMPROVEMENT PERNIIT #: ,QI� �/
TAX MAP #: PARCEL #: ��„ .
OWNER/OWNER'S REPRESENTATNE: �th � �'ar✓�!����1/
LOCATION/ADDRESS:
SUBDIVISION NAME:
SECTION OR BLOCK:
AUTHORIZATION FOR
0
ISSLTED BY:
AUTHORIZATION CONDITIONS
LOT #:
1. The Wastewater system construction and installation must meet all of the conditions of the
attached site plan and specifications as set forth in Improvements Pernut #�1��. The
construction and installation must also meet all applicable niles and laws.
2. No portion of the Wastewater system shall be covered or placed into use until inspected and
approved by the Person County Heatth Department.
3. Any alterations in site or soil conditions (including stcucture locations) or modification in use,
design wastewater flow, or wastewater characteristics as specified in the associated improvement
permit and application, may void this authorization and associated permits.
4. Conditions:
Permit written to allow the
c
� �\P✓C� bn�
� /����c� '
�///�1 f y, �
, A IIY /1. ..)...I r. (�1.�� �rhQ
with no chanQe or addition to the existing sentic s��stem
Person Requesting:
06/04/1997 16:16 5971799 PLANNItJ� AND ZONIt�Ki PAGE 05
' . . . fi • ' •, .
, `` y _ ' • . � ♦. • ".�}� - �� � � ' � • V
` � ••
. , �, . ~*," �c se�•sa�oe�� '�.�. JANUI
-� „R r�ti,,.. c �av.r'`,�� 4�. s3 � � . . � . . ,
+'+._,r��' '� "'^'�',P � S�+•5�1�1$�E '. � ' . , .
" �- '.i' .Z . 88' ' . �: ` � ' .
` �•" J2 . 83' � �`' 1. 34' 'o( . . . •' �
IF NfE •' � • • � .
� _ .85' ���. , � � • ; ' '
��� C�,x '� ,o� �s �� e4,� �`�. .�.� 1 X�;L�
,` � �,,, �'�'�jr, . --� � , !1 .
f � �� � ' � ' •�� � -
( (7 `� �� � � . • .
� .
, ty � �. l
� v � �` � I 'r�i � � ` .� ,` , �
w (
.
�'''�, c� z � � a D Ir• ,���� /� �'/ . � .� .,�,.'!/
V . y_, .
'� V
� � � ^ :� � �..�a � � �^ r, � � .
q �. /
�c�,l, — ` b� �
r �+
�/ � �� � yl��,�,,+� � � a � !
� i• � ' ° /
cY"�� '`" � �,�' I l '�
. � � / �� S
u � / � � •=
/ � �
• � / . ��—/ '=� GQ - - .S'%.S�
t5 r I `� O � �-
��`� � � � � �s
i k�� "��'���� i � .
I �rs� / �
� I I � , .� .
/ � � � .. I� � . .
� � �� . � ,��,�.��- .
t • ' �,a � � � , . � � . . /�5�� 0 .
! ^ �
r � 4 f � CLYDE`NiLI.IAMS, dFl. • ,
� � , / D-B. 1�4. P. T12. . .
. �;N � � ' .i� . .
� 1 � � � • - �
� . - .
/
c�� �j / � . . � . . - .
� / . . . ..
!/ � . , . � . • �
. !� � . . . . , . .. � . � � . _ • : ., • .
_ �/� , _ � � , . . : � . • . . � � _ . . . , ; . '
r� . � . � • � '� . . � . .:
� • � • -
� / � _ - . ��.: � � �.� ._ .
� � � � � . � . • _ � � ; � . _ • -, ; .
�! � ``� � � � . : - .. ' � .' . . � � " � . ' ' � � . � _
. �. � `� ,� � � � � . � . . , . . . .
• � • _ . : . � • .� ! �� • � .. . . . - . . • � ' , . . � . . . ' ' • • . • •. ` ' ...���
07l22/1997 18:10
.
12 �C1-1'�9� ��4�'1
8044547843
BEt�ETT WELLDRILLING
PfiL1r. PE�'SG��1 �.OUNTT Ff�A(,fh :t�PR «;;
�E�54N CDvNTY �tavLtnb►N�N1��, �?EnLTN
PA�E 02
t`.'�44'.'��aa�i F, o::
� tteL�- r.oC
i��tC; �
t�ws�er. � SR# 3� 3
tt�Cation ' eCtiqns:
� _.���..�
$ub�lvlStOl1 i�atY1�: Z.At � � ,
t3riti�g Cc�nueccOr' • -.---r--�—.__
Diac�ce !'Yam N�arest Pzqperty Line____ _ Diswx� fram S�urce a�
potivtion �
Tot�t I)cpth: /�`�,,,,�, Ft. Yi��d:__.�,__,,, �plvi Static �:ter Levei �F
.� _ �., t.
W�ter R��rt� 7Ants: Dapth,;,�,r,r„�t.,_._,,�,,,,,,�L` . . _Ft,.,�„�,.,�i.
��tsin�: Degth; From,,.,r,{�,,,,rq,�,,,_�t, Di�an�eter. Inch�s
.
TYPE: Sceel . "
Galva�i�+rrl St�st...,: , ._..,._��. .� ,
lf S�a�l, �aes own�s �ppr�ve: Yc�,;�„!�„�ta�_
waight:,�„�,�,,,�„'I`hicl�cs�:`�;,,.�{right Abovz Gr�und�� Inches
Dri�e Shoa: Ycs�_ No �
1aYare �roblams £n�a��erod ir► ��ecr,"��; �ha Ctsing? Y�s_,_,_,___���..^- --
Ii "yes" ��va reuan:�-
Graut: Ty�; �ie�t �� Sand1G'en�ent Concre�c��
a�u��.s���� w�a� � ' �n�t���
Waecr i� Annulu� �p�c+�: Y�ex,_„`,�,,, No ✓�,
Iv�c�hod: P1�mped_...,.,�, Pressw��� �aured_�.�
i��iY�i: i�r�1i��•u�i �r•.���.��. �a � T1.
Mttariat� t�sed: No. Bags Portlu�d �emt�t�.� ,_ VY�igty� af 1 bag�,lbs.
if mixtuxe ts�nd, gr�ue�: cutt�r�gs) •��ua:.� ___� to�,..,�,
I D Pl:te�: Y�s,r ,3r,,..�,,,, No __ .
Y x�R�s� c�R�nF�r TH�x rr�� �aov� �p��,i�,�o� 1S �:oRR�Cr aNv'r��3
rKis w�Lt, WAS CO�tS7RUCT�� xN ACC��DaNCE wi�N RE��ULA?IOKS SE.T
FORTH �'f THE PERS��! CbUNTY NEAL7N D�paRT�l�tYT.
�..�� _.._._.._�. �...�...� ��-�
Stgn,��t;:� �f Ct�n:�ac���� ir.��r�