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A24 166
���� �� ���� �� �� 1 1 .J � � ���� IE�.���� � ��.¢.�.11 IEIL��.Il.�. T�x M��p Pa:rc�ei � S�uhd;ivis�io�a Ph:��s�e`Sec�tia,i�� Lat � .�- Applicant: � C�`. �-e.z_ Location: � � � �' : � ' , . ' .!: ` . '`� - System Type (In Accordance With Table Va): ... ��.-� TH1S SYS?EM HAS BEEN tiVSTALLED IN COMPLIANCE WITH �►PPL.ICABLE NQRTI-B C�►ROL]M�► GEiVERAI. STATUTES, RULES FOR� SEIIVAGE TRE�►TMEtdT AND DISPOSAL, .4ND ALL CONDIT101dS O� T�iE IMPROVEMEAIT PE4�IVIIT AND. COPISTRl1CT109V AUTHORIZATIQN. . . . �,� G` , . r , - � . - �-�,3—c��� . . Authorized State Agent - • --- -�- � Date . . � :. .. . � . ,. instailed By: �.i. � =�f� . � Date: � �_�- � ` � .; �— . --- --. �..�, , - �. �� ' ( _ ____ , __ - ,� � � -1 , � �;� 1�-�, ,, ,��� ''��r r�� 1 ,�i �1 f ., (o � � Cp��( i C� � ``� ! ' i `� � i � � �. 1�� , . .� � - ���.� � � � "�� 1 �' ' ,. . f , � ;�,: :' I• � „�.- ., � ,� � �1. ; ;;:, � :`� . f� � �..i�-_.`� ��� :4 ; � ,� .� 7 �,� �\ '� r„ ,\ v� ., \� aa'' r� �,1 r . j �- `J � �PCHD, rev. 07129/b2 S�#�T1C TA�lE� B�SP���lOP1 ��lE£�1S�' ('iype ll - i�� Ta ; Map #/� �.,21 Parc�l # 1 rr t,- System Type (Table Va) 1��. OwnefJA�pficant `� L� , C.�_.,�. Subdivision �.:--- AddresslLocation ��-,�Q ,�,,�_� Se�lPhase •-- Lot # �- Septic Tank ni a ate �tn ca�on nes ni�a �� . . St2te I D/date � � - � r , n `' S'(%''�'" �' � � Trenct� 1�lidth � ft. � � Capaciiy. ;�,�-.� . gai. Trenct�. Depth a_t� in. �• . Tee and Filter � . Trench Length '�: ; ft. � , � 8affle - � ; Trencf� Grade .! ' ��' �,, ti f , �_ � Sealant - ,.5�" ..� Tre�ct� S ac9n9 �° r'' f,. �Nr.�. '. . Riser if applicable - '"" Rock De th and Quaii � :;� �; f`. Tank Outlet�. Seal � Dams/Stepdowns etc. � � � � Permanent Marker �./l�-- Pressure Laterals —y-- � � � Pump Tank Hole Spacing . � � tate ate � o e ize � � Capaciiy gal. � s Pipe� Sieeve � Waterproof /Sealarrt �� Tum-ups/Protectors � � . Riser ; Requir� Setbac�cs . Water Tight � � From Wells �: . ��" Pump ; Fr.om Properly lines � ,�` . ; Checic VaIvelGate Vaive ; . Structures/Basements.. .. ..., .. : � . :_ t�-s� on o e itc es ramage ays � �� '.. .- . Fioats/Switct�es � � . . . . � ., . _ . SurFace Waters � - a� , .. -- Alann visable and audible i Public Water Supplies ;; �'.;� � .�r� � Eiectrical Components � Vertical Cuts >2 ft. ��:��` �� ��' � Rate gpm �. Water Lines . � �`-y � Approved Pump Model Vehicle Traffic �' ^y+� Blocic Under Pum � Ad�acent�Systems �. � � Pump Removaf Rope/Chain � EasemerrtslRight of Ways �€� � � Distri6ution Sysiem ��e� . , Seriai Distribution• ,:� � � c� :z3-�9 Easements Recorded . . ressure an o e perator ontract Low Pressure Pipe . • Tri-Partate Agreement Ap r. Pipe Material and Grade - Valves . � � � � Comments� " ; � . . ; � � pci�d rev, �7'13/01 .���;�� ���.� � a �. - �_ � ;o ���� 7���a-�,*„ ,.,,,, ,���.�.Il IE���.Il�� , •. - � � .. • .. � � /L.�i..� �/- =:�!/ — - ' � / ��� -� ' •-� s�'�'�. 5����. Tag lYlap #�.Parcel # I�O Section/Lot# D � / � �o�-f Date System components represent approacimate�contours on�. The contractor must, flag the systernprior to beginning the installation to insure thatpropergrade is ma.intained N 02'S0'S9'W 274,60 � � ��(Y� �' `-a, SC�e: N � N I �l= � �� _ �' � — — — �, S Q . � � 2 Wv, \ � � � � \ -A'� � f �' � `� � �'� :�. .� 6, � o� ..< N � cn r,� s . .� , � CO rn . \ �a • � \ • � :+: . � � � �- �� � � � .� -� � A ' Q � \ ~�, �, (n � � � i � n o b C� cZD • � � -t � . � 290.30 . �- `" '.'', 2'17'S7'W ; , 39.84 _ ' � � `,;., ;�� : S 0 •4p� ' 9•�„/ — --.-- _ ` . ,, , — `" � � .�.�o o � � � �- � . �, �� �'� o R � ,� � , . . "� Y���. 2'.. �j � . 3." �cRS..aa'..a..,, 7 < "' • . � '. . � / � . ��,I� , � PG�ID, rev. 09/12/01 �� .S� ���..� �� � . .�, � �c�:� ��T��Y IE��aa-��rn ;:-;r;, ��.��:71: IF]L��II�I�: �W11CC: .,. Location: � Subdivision: o�a� ao � �2 �' � �[� �rne��-�c l�el1 I�rrlJ%� � o� 7 —I S —��. r....,.� T ,,,. Lot # � Well on�traction Distance From nearest Property Line (Minimum 10 f) �,J Distance from Se,ptic System (M' 6.0 feet) Total Depth: � 6 Q ft Yield• �� GPM � Static Water Level: 2� ft Water Bearing Zones: Depth ft ft ft / Casing: � /� Depth: From �_ to n ft. Diameter: b � in Type: Galvanized Steel � � Weight: Thiclrness: j/� Height above Ground: � in Drive Shoe: _� Yes No Any problems encountered while setting casing7 _Yes �o If "yes" give reason: Grout: � Neat: Sand/Cement Concrete GraveUCement ✓ �. Annular Space Width � inches Water in Annulaz Space Yes ✓' No Method of Grout: Pumped Pressure Poured ✓ Depth� to ��' Ft. Materials Used: No. Bags Portland cement � Weight of t Bag �% Pounds If mixture (s , gravel, cuttings) — Ratio t�o--�-- ID plates: �Yes _ No 4 x 4 slab✓ Yes _ No Liner: - <.� Depth: Date Installed: Grout: Installed by: Drilling Log Location Drawing From To Formation � u�/�� �� � �3 �P � G , c � C> � �� � � � , S�°re �Z 3 � I hereby certify 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 S =�� � Signature of Contractor %%� ID# �� �� Date . Z� _ Pump Installment Pump Installation Contractor: I�� rn� �� �,/e f 1 �r � I, State Registrarion Number: � G� pump Depth: � ��' ft �t'abc Water Level: 2 ft Pump Make & Model: � PJ_ , l�GKC�' Pump Size and Rating: � Z hp l� gpm I hereby certify that this pump was installed and the well head completed according to the Person County Well Rules in effeet on this date and that a copy of this record has been provided to the well owner. . Pump Installer Signature �'-' 1��'�'---_--- Date: � ���PCHD rev O1/27/04 04/01/2064 15:33 3365991806 JIMMY LEWIS PAGE 02 ,�,�, �: �{--�� - � `� � .�, �� � ���� +�: - i�� �,r�?..�.� ���.� �� � � � �7Z�•T"`�'�.' �.a�-+�.�-�.aa�.�as�s.,a ��.r.nt6�. - . ! • .. .! � =1�:1J�+f . 7) Prrmlt rarqiwst�d r: (Own4 ,�praspe�►� ow+�): Nome phona: Addresa: Buairte� Phons: 2) Narne ar�d �drir+e�� o� ezur+en# �+vn�; . � 3} Property pa�cdptlon; Lot size: „�._,�"�, TownahlP: ' b�vislon: Lot � Qir�ctlon$ ta the pra�ty (lt�aluding road nsmes a�d num�ra . di Propa�d Uai and SEr�aEur+� Dvscriptian: an�vwer �ri of the fintlarving qu���s. ' �) �P�l � Existtr� .� i1+Pe bf Structure:,��;;� gc, h"�e�rl Wfdth:_� th: b) Number �' �ednoama: ,,,,� Number af oax�pants ar peopl� ta l� serv�d: � � c) .�asemer,� Y�_,, No _,,,�, Wll1 th�re ha plumbin� In #he be�ment? c� 6arh�Se Dl�pa�al: Yea,, No„ � Ws�r Supply TYpo. 1�riv�te �. (r� ...^ o� exlsttn�,� Pubtl�� C,�mrnunity:,�,► �� wetf� �orti adjoinln� proPert� Ye�� Na , tf yes. plesse �e ap�m� laa�tkm an tlte ��O� ��Pp�Y aanbpin pne�Wvt�ly W��tltiod �url�dlc!#onai wvt�nds? YM,� No � ��i� i. . .� . � . � - -- - - - - . �..�3 � A�L,A7 Q�'1'HE PRdPERTY CR �11T'E PI AN MM�'t' 8E l4UBYlTTED YV11'H THI�1 APP�JCAT10Fi. � PtZOPE1tTY l,lNES ANQ CORN9t8 MU�T B! CLEARLy IIAI�1RK�p�. , D TNL PRDPCIS�D LOCJ1TIbN �F A�. STRl1CTURL� MUST 8� SY/�J�D OR FLAG�D. A THE SRE MUST B� RE�wp.Y acC��a1�L� POR IW EVi�[,UATtON � TH� H�ALt'H DEPAR7'MENT ��'AFR. shereby make �pplk:a�an ta the Par�x� CauntY Health 17epertment fa s s�e evelua�ton � tt�a on-s� se�wrage diapa�al ystvm for the abol+a-deer.r�bad praperiy. I a9ree that #he cont�ents o� thls sppltc��ivn er� tru� ar�d r�pres�nt tha m�udmum fadlUl�s tn be I�lac�d on tite �roperty. I unde�#and H' tt�e site �a altaned or tt� Ir�ended use ctt�ng�s. the pgnnit ahell het�m� ir�al . Ovm or L�tl Repre�v�e �•� � i. r �. £/L 809LLB49CC 4i1��H 19�u°�"Wo��ny� 'op uoe�od WV 95�80 t00E/10/tU '���,/� ������ � p ��^ � V ��� IE,m-�y-�� � ��¢�.11 1H[��.Il�11� Name �. C• l�,►. Su division � Autho ed tate Agent SI'TE SI��'CH Ta.g Map # A 2y .Parcel # l�� Section/Lot# 3 - a3-oc� Date System components represent u�iproximate�contours only: The contractor must, flag the systemprior to beganning the installation to insure that pro�ergrade is maintained ��� �'� y�� Cy1�+r.c�- .' I' �� .��r — (Ylc.��" ►�^ 3 " 4 � � �'�e S�,c 33C� _ 5g9 -- �O 14 7 f.�` � ,� je �o cs�� tw �sam o�c ��,�o.Q � . 33ca -5a3� 3H ��! cca.� i� �i , '�Y17n t� . � / //� e��C ' �x �x nc . i '� � � - .} T� �' 1 / ` � "� . ��,� �...,'� �.. ' �`�.�, � . �, c�. ��.�.. -�. , �cale: No�- -� / a ' `t f�c¢ss Eh�y Cu`9- -�. � �,�.Z 1;1�a.� �,.Y�..n ,,�.5�-c.Q.J�� '� VFec.�vic;�, _ �� ,,��„� �..,� he�2n �� G"�' � �r t�nwl�- �C. ��.;� c�•�.�- . �� ��� �X c�.s . ��Q PGHD, rev. 09/12/01 � ' �,�� �� ����J ��- V �.. � � �,�� � � �J 1.. �1 � � ��.v�.a-�,�-t+ �.,�„ ����..�. �J.'��.m.��1'� �x Ma � � arc�-e : S � � cilivision � h�.s�- Sec i�+a; ot ; � of ediraoms A�plicant: � /�"zc�..�+1�- �'�' ��1`�s�-�, - Location: � � , . - . ���#i�r� er i.� . . Sysiem Type (in Accordanc� With Table Va): TH1S SYSTEIVI HAS BEEN If�ST�4L1.E� IN CflMPL1AMC� WITi-{ APPLICABLE NORT}f � CAROLlYyA GEiVERAL STATUTES, RUL�S FOR S�iJVAGE TREATMENT AND DISPOSAL, AND ALL CONDIi7�NS OF ' Ti-lE 1MPROVEiVIERlT PE�NII7 AI�D CONSTRUGTIaN AllT ORfZAT1�iV. � • � 3- ��r�e ' .. Authorized St te Age �_ Date � Installed By: �3 Daie: �� --0�%�C� � � � � �.�4r� . . . � / . ��� �-er- � � � �n � `�`� � t � � . . �,; � r�� . . � �, . . � 1 z���� /� � Z� � `��'i P�4 PCHD, rFv. 07/29/0� a ����� ���� �����'���.� ���'��...��v i ��� �� - �� Tax Map # Parca� # Sys�esr� Type (?a�le Va) � Ownerl��plicanf Si�bdivisio� Address/l.ocation SerJPt�zse Lot # � State �ID/date Capaciiy gai. Tee and Fiiter Baffie Sealar�# Riser (ifi applicabie) Tank Ou�et Seal � Permanent iVfarker Putnt� Tank � � Wate roofi lSeaiant Riser Water Ti ht � � Pue�p . Checic Valve/Gate Vaive and audibie � Rate m A �rove�i Pum ii�ode! Block Under Pum Pum Removal Ro elCnain . �•Dis#ribu#ion_ SSy��an � Serial Disin'bution ressure an o Low Pressure Pi e A r. Pi e I�Aaterial and Grade VaivFs - ' -- s r���r�c��aon �,tne� Trenct� �cifih � � ft. � Trer�cll De � � in. T,renct� Len fi. Trencti Grade � � Tcenct� S ac9n Rocic De th and� Quai' DamslSte downs e#c. Pressure Lat�rals � Pi �e. Sieeve Tum-ups/Protectors � Req�ai�esi' Seffiac� � From� VVells �� � From Prope lines � Structures/Baseinents rt es raina e a � � Surface Wafers Public Water Su lies - Verticai Cuts >2 ft. Water lines Ve�icle�Traffic � � .. Ad'acen# ms � � .' �Easeri�ents/Ri h�.of Wa . Otteer . � . Easements Recorded C�rnmenis �ct�d rev. 3/'i :JQ1 ���.5� ���.��� �--= �--�- � � ���� IE�.��-�mm ���¢.�.71 ZE3L��.Ilv�11� WELI. PEI2MIT I'I.EASE SEE A'I"�ACHED PLAN FOR WELL SI'TE LAYOU'I' Tax Map #: Z� Parcel #` �� Township � Applican� J � � • �� '�- Subdivision: Section: T�pe of Water Suvulv: Requirements• Individual Site App=oved bp 'a � � � -�� Grouttiing A=oved bp a-� e- � �%� I.Ug -� - Well Tag S � Air Vent . Hose Bi� �oncrete Slab u,� �g-� Well Driller._ Well Approved 3'Zo —o �. Community PubGc ..�r; r � �� �I L r�'1�,,.`'' ' y, ` � u �� � � �,.,ar�c, i.� N�us,- _ � ,1 �,,��'`�''� '�°5ee Attached Site Sketch'� ells must be 10 feet from property lines. Wells must be 100 feet from septic systems. We11s must be at least 25 feet from anp building foundation. Other conditions• PCF�, rev. 09/07/01 ':���,�.� �1��' �� �� � �� �� � � �- . � ,o�-�a� ��� �����,� � :���.� ��.�� ...- / � .. • -►.. � 6L .,�� �t%- —',.•'� -- - - , / • � r - � ' � ' a � ���. �����: Ta� �ila.}� #�Parce�. #� Section/Lot# Q y��-�� Date . �� Systesn cmrrr�ione�r re�ir�se�ai itp�iroxirnate�con�"ouTs mn1,y. 3''rze contractor qrsurt,�dag �.�ae syst�aa pssor to begeszni�sg t�ae iras��ullact�re #� a�saar� #drat ps�o�iergr� is �ared � � Oi � N 02'S0'59'W 274.60 ' �90.30 � . � 02'17'S7'b/ •. < ,� �:: . ����:� a,;N �:��. . _ � Scale: � , � i � = I �' . .. / . — — — � � �- � 3 � �' x � ; Q y Q � \ � .�SF �Y"µ.. � . ; ����� � , \ x . "la i �'-*j �Y N N ' �4 + ��.� ^� � N � ������. O �p _ H ,'k= ��' �`.r� I � : .u,�p.n�.:� �� ..�.,.3K�..; ; �,+Ft=!^ti:.M . i.)1 " r � �' CD m � � � cD � ' . -�..;.�, ,.; -� \ ' \. ;r � —_ — �� ��' �; :. ;�;� ' '\ '� �-' �� . ". . . Q \ ::'. ,:° �. tn � _ - � n o � vo � _. \ �' •R� r�'n � . �i,Y 39.84 � � � f •4a, • 9sW— _' ._ _ _, �,, � . ' . ' ' G"�:,"'yii? i` _ ,M"�. �::= � - t: �•;;;::r - �.� �� , _ . I'��, ��. 09/."�7�/9�1 . . . vn �-��, ?��f ���� �.J�l V �...� � � ���� IE��n������¢.�,.]L IE33L��.Il�]]� Applicant: � • Location: �� . �' Ta�x fu1aE� � ' Parc�el # ,� � Sinc�livi�s�ioi� IFh���se Sect�ion Lot �' Improvement Permit Permit Valid for Five Years No EgpiraHon � Type of Facility: �J �j IL 5 F�i New ✓Addition _ Water Supply r� VQ,%�_ # of Occupants �# of Bedrooms _� Projected Daily Flow 3� 2 g.p.d. Proposed Wastewater System: CDr1 VP.,�L�-:o►�4 Type: Proposed Repair: �7� (� q���,�..; �,�,�Q Q Type: Permit Conditio� Owner or Legal Representative Signature: Date: Authorized State Agent: p ,�1C Date: , --� ..., The issuance of this permit by th`e'�Iealth Department in does not guarantee the isauance of other permits. It is the responsibility of the applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements aze met. This Improvement Permlt is aubJect to revocatlon 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 compllance with the provisions of the North Carolina `Laws and Rules for Sewage Treatment and Disposal Systems' (15A NCAC 18A .1900). � Authorization to Construct Wastewater 5ystem �Required for Building Permit) * See site plan and additional attachments (_). Proposed�Nastewater System: n�P.(1'�� �� Type,� Wastewater Flow 3(Q(2g.p.d. New �/ Repair Expansion Soil LTAR: . 3 g.p.dJ ft 2 Type of Facility: 3�� ��.1� Basement _ Yes ✓I�o Wastewater System Requirements Tank Size: Septic Tank: � D�gal Pump Tank: � gal Grease Trap: N� gal Drainfield: Total Area: (� sq ft Total Length �_ ft Mazimum Trench Depth 2�_ in Trench Width �J ft Minimum Soil Cover: _�, in Minimum Trench �Separation: � ft Distribution: Specifications: Authorized State Ag Permit Distribution Box ✓ �erial Distribution The type of system permitted is ✓ Conventional Innovative the permit. Owner/Legal Representative: � Pressure Manifold Date: ^- �'d Alternative. I accept the specifications of Date: